Patient Satisfaction, Esthetic Outcome, and Quality of Life in Oncoplastic and Reconstructive Breast Surgery: A Single Center Experience

Oncoplastic breast conservation (OPBC) has become increasingly popular over the past 3 decades as it merges the curative intent of oncological surgery with plastic surgery techniques in an attempt to resect larger or multicentric tumors with breast-conserving procedures [1, 2] thus reducing the necessity of performing mastectomies [3, 4]. Retrospective reports have also indicated a reduced rate of re-resections after OPBC [5], yet with a significantly higher morbidity rate [6].

Although the oncoplastic approach is a common practice in certain specialized centers around the world, some breast centers do not offer OPBC. We observed that lesser-trained surgeons tend to offer their patients a simple mastectomy option. Moreover, some surgeons in the past did not seem to be convinced that OPBC with its wide range of different techniques may have advantages for certain women with breast cancer [7‒10]. However, the oncologic safety of these procedures has been well documented [11‒14], and they have become an important pillar of surgical treatment over the last decade [15].

It remains a widely published topic in the specialty of breast surgery, with recent additions of large retrospective cohorts, reporting improved quality of life (QoL) compared to reconstruction in DCIS [16], or stating that even though oncoplastic surgery yields higher wound complication rates, postoperative adjuvant radiation is not delayed [17]. Scientifically, one of the reasons that OPBC is not offered at all breast centers may be that prospective data based on validated quality of life tools comparing breast-conserving surgery (BCS) and OPBC are lacking [18, 19], with recent publications mostly focusing on one group only, which found a high rate of complications after oncoplastic surgery; however, this did not impact overall patient satisfaction [20].

To add data to these questions, in our center, the immediate Techniques for Oncoplastic Surgery (iTOP) trial was initiated in 2011 to prospectively compare patients with breast tumors. They were treated in regular breast-conserving, oncoplastic, and immediate reconstruction groups to objectively assess whether any group yielded superior QoL outcomes, as well as to prospectively collect morbidity and oncologic outcome data. We reported favorable outcomes in all groups, but no significant differences were observed in either the Body Image Scale (BIS) or the BreastQ questionnaire [21]. To further strengthen our findings and in an effort to quantify all oncoplastic-operated patients in our breast health center, we analyzed all patients operated between 2010 and 2018 in a cross-sectional study and compared their patient-reported outcome (PRO) scores with internationally published data.

All patients who underwent any type of oncoplastic surgery between 2010 and 2018 in a tertiary university hospital were included in the database. We invited all the former patients to a follow-up interview and examination with photo documentation to our outpatient department and asked them to fill out the BIS, version 1.2, by Hopwood [22] and the BreastQ version 1.0, by Pusic [23].

The BIS by Hopwood sums up to a maximum of 30 points, with fewer points indicating a better result. The BreastQ is subdivided into 6 independent items with values between 0 and 100 points, 100 being the best score. Those are satisfaction with the breast, satisfaction with the operation, psychological well-being, physiological well-being, sexual well-being, and satisfaction with the nipple.

Additional patient data concerning operation type and date, pathohistology, neoadjuvant or adjuvant treatment, and oncological recurrence were retrieved from the hospital’s electronic health records. A total of 157 patients were identified and contacted by mail or phone, of which 100 could be reached. 39 patients declined to be included; 61 agreed and appeared to the check-up, answered the questionnaires, and agreed to photo documentation to calculate breast symmetry with the Breast Analyzing Tool (BAT). The BAT was designed to objectively compare breast symmetry, resulting in the Breast Symmetry Index (BSI). The BAT is a very intuitive software, using frontal pictures of the patients. The examiner hast to manually mark the jugulum, the nipple position and the breast contour. Lower scores signify higher symmetry and, therefore, a more aesthetically pleasing outcome. BSI scores below 2.5 corresponded to an “excellent” outcome according to the older Harris scale, BSI scores between 3 and 6.5 corresponded to a “good” outcome, 7–10 were “fair” in Harris’ scale and over 11 matched a “poor” result [24, 25] (Fig. 1). Fifty-four patient data sets could be used for statistical evaluation in the end. All patients provided written informed consent (Fig. 2).

According to the Tübingen classifications [26], we subdivided oncoplastic procedures into three groups. The first group consisted of Tübingen 3 and 4 procedures, tissue displacement techniques with less than 20–25% of affected or mobilized breast tissue, such as batwing, doughnut, or round block techniques.

Group 2 included Tübingen 5 procedures, which are complex reduction mammoplasties and volume replacement procedures with over 25% of affected or mobilized tissue, such as Hall-Findlay, lateral, inferior, or superior pedicle reduction mammoplasties.

Group 3 included patients who initially or eventually underwent implant- or flap-based reconstructions (Tübingen 6).

Revision surgeries were documented within the first 6 months after the initial surgery during regular check-ups in the outpatient department of the breast care unit. Additional surgeries were performed during the entire follow-up period.

All analyzes were performed using SPSS 29.0 (IBM, 2022). Two-sided p values below 0.05 were regarded as indicating statistical significance. For parametric data, ANOVA was used, and for nonparametric data, the Kruskal-Wallis test was used for comparison between all three groups in this study. Correlations were calculated using Pearson’s correlation coefficient.

In total, 54 mainly Caucasian women were included in this study. There were 16 patients in group 1, 26 in group 2, and 12 in group 3. The mean age was 53.5 (±8.75), 51.4 (±9.51), and 46.8 (±10.72), respectively.

Two patients in group 1 required a second operation (12.5%), compared to five (19.2%) in group 2 and eight (66.7%) in group 3 (p = 0.003). In group 3, 6/12 patients (50%) were initially planned for mastectomy and reconstruction, while the other 6/12 (50%) had initially breast-conserving surgery with or without oncoplastic techniques and had to receive a mastectomy and reconstruction as secondary surgery due to R1. Two patients in group 3 had contralateral symmetrization (16.7%). Two patients in group 2 (7.7%) had to have revision surgery due to R1, another two (7.7%) had contralateral symmetrization, and one needed axillary dissection (3.8%). In group 1, 1 patient had contralateral symmetrization (6.3%) and one needed axillary dissection (6.3%)

Eight patients received flaps (66.7% of reconstructions, 5 transverse musculocutaneous gracilis flaps, 2 deep inferior epigastric artery flaps, and 1 transverse rectus abdominis myocutaneous flap), and 4 patients received implant-based reconstruction. Fourteen patients (25.9%) had contralateral reduction mammoplasties for symmetrization. In addition, 8 of 12 reconstructions were placed prepectorally (66.7%), 4 retropectorally (33.3%).

Five patients (31.3%) in group 1 received neoadjuvant systemic therapy (NST), compared to five (19.2%) in group 2 and two (16.7%) in group 3 (p = n.s.). The most common tumor size was pT1c in both group 1 (9 patients, 56.3%) and group 3 (6 patients, 50%). Groups 2 and 3, however, naturally included mostly larger tumors such as pT1c, pT2, and pT3. The majority of the tumors were ductal/nonspecific (81.3% in group 1, 88.5% in group 2, and 83.3% in group 3). Negative axillary staging was found in 11 patients in group 1 (68.8%) and 19 patients in group 2 (73.1%), compared to 6 (50%) patients in group 3 (p = n.s.). Luminal A tumors were most commonly found in the final immunohistochemistry, with 9 patients (56.3%) in group 1, 14 (53.8%) in group 2, and five (41.7%) in group 3. Mean follow-up was 53.4 ± 35.29 months in group 1, 71.7 ± 35.14 months in group 2 and 56.6 ± 36.20 months in group 3 (p = n.s.) (Table 1). Only 1 patient in group 2 had an in breast-recurrence of the carcinoma, and 1 patient in group 3 had a regional recurrence at follow-up.

Patients in group 1 reported a BIS of 7.69 ± 4.48, group 2 yielded 4.81 ± 3.41, and group 3 had a significantly better BIS (3.92 ± 1.73 (p = 0.016) (Table 2).

BSI scores were 8.38 ± 3.19 in group 1, 6.50 ± 3.30 in group 2, and 6.21 ± 3.28 in group 3, years (p = 0.12), respectively (Table 2).

Numerically, group 2 shows higher mean scores than the other groups over all 6 items, with “Sexual Wellbeing” being significantly better (p = 0.036), reaching a score of 80.35 ± 22.85 and “Satisfaction with the Operation” with a possibly clinically significant difference (p = 0.14) (Table 3).

Pearson correlations over all groups between age, BIS, BAT, and the BreastQ subitems showed significant correlations between age and BreastQ’s “Satisfaction with the Operation” (0.325 coefficient, p = 0.016), between BIS and the items “Satisfaction with the breast” (−0.505, p < 0.001), “Satisfaction with the operation” (−0.328, p = 0.015), “Psychosocial wellbeing” (−0.642, p < 0.001), and “Sexual Wellbeing” (−0.524, p < 0.001). Objective symmetry measured with the BSI did not show any significant correlation over all groups or in each group separately.

Ultimately, all patients who underwent any type of reconstructive surgery, either with flaps or implants (n = 12), were also compared to patients who underwent breast-conserving surgery only, so groups I and II combined (Tübingen 3, 4, and 5, n = 42). Again, no significant differences were found in subjective QoL tests or objective symmetry.

We classified complications according to the Clavien Dindo score, as used in our center before [27]. Five patients in group 1 (31.3%) had minor wound healing defects, corresponding to a Clavien Dindo I score, 3 patients in group 2 (11.5%) and also 3 patients in group 3 (25%). One patient in group 2 (3.8%) and another 1 patient in group 3 (8.3%) had a wound infection, corresponding to a Clavien Dindo III score.

Oncoplastic surgery has gained popularity among breast surgeons from general and plastic-reconstructive surgery, as well as gynecology sites. Depending on the treatment in the breast care unit, the procedures are performed by a specialized breast surgeon or by a team of oncological and reconstructive specialists [28].

Due to this massively growing interest and driven by the idea that aesthetically pleasing results improve patients’ quality of life, self-esteem, or body image, many retrospective studies have been conducted in the past. Thanks to these studies, a lot of data have been published with contradictory findings. For example, cosmesis and satisfaction are correlated with the excised volume [29], but the objective symmetry of the operated breast might not influence the overall quality of life and satisfaction [30]. Interestingly, the higher complication rate in oncoplastic and reconstructive surgery, such as wound site infections, did not significantly impact the overall satisfaction of patients in another large retrospective cohort [31].

Our data confirm these findings in part, as objective symmetry (breast symmetry index, BSI) does not impact BreastQ or BIS scores, although interestingly, larger oncoplastic operations with a greater amount of excised volume yielded significantly better BreastQ scores. We compared the BIS scores, as it was also used before on oncoplastic patients, and showed significant superiority of oncoplastic procedures compared to mastectomies without reconstruction in a validation study. However, it was not significantly different from regular breast-conserving surgery. The reported mean BIS of 6.10 ± 5.31 was slightly better than our reported mean in group 1 and slightly weaker than that in groups 2 and 3 [32].

A Portuguese validation study published data from breast-conserving operations compared to mastectomies without reconstruction. The BCS group (n = 51) had a BIS of 4.9 (SD 5.83), which resembled our data from group 2. The mastectomy group (n = 122) had a BIS of 10.3 (SD 7.81), which again demonstrates the need for reconstructive surgery [33].

Similar to a large Danish study with a total of 627 conservatively operated and 95 oncoplastic patients (Tübingen 3–6), patients in groups 2 and 3 tended to be younger and had larger resection volumes and tumors. In addition, the odds ratios, albeit never significantly so, showed higher BreastQ scores in the items of psychosocial well-being, physical well-being, satisfaction with the breast, and sexual well-being, mirroring our results [34].

Normative data of the BreastQ, however, were rare, until a large study from Dartmouth College gathered data from 3,600 healthy women to present the BreastQ to compare breast cancer patients’ scores as a clinical reference point. In their reconstructive set, patients reported scores of 58 (satisfaction with breast), 71 (psychosocial well-being), 56 (sexual well-being), and 93 (physical well-being) compared to 72, 86, 80, and 72 in group 2, respectively, which showed high satisfaction overall. In the mastectomy group, they showed normative scores of 58, 71, 56, and 93, compared to 71, 81, 65, and 72 in group 3, again showing very favorable overall results [35]. Interestingly, the highest score for sexual well-being in this oncoplastic cohort (group 2) might be explained by the less favorable sensation of the nipple-areola complex of a skin- or nipple-sparing reconstruction [36, 37].

The largest limitation of this study was that data collection and patient invitation took place during the COVID-19-pandemic, which affected the normal processes in our outpatient department. Many of the invited patients did not want to show up physically due to fear of infection, which negatively impacted the overall response rate. A small number agreed to send their questionnaires and images digitally, which might have impacted the overall quality of the photo documentation. The patients who showed up were interviewed with all necessary precautions according to the hospital’s regulations at the time.

A total of 12 reconstructive procedures with 8 flap-based procedures and different flaps used is also a low number to gain distinct findings. Also, patient satisfaction differs based on the respective flap, some studies favoring the deep inferior epigastric artery flaps and others transverse rectus abdominis myocutaneous flap or other donor sites [38, 39].

Also, we continued to use the BreastQ Version 1.0 since the team was very well acquainted with this initial version, and we were able to compare our own previous data to this newer data better. For future studies, we plan to implement the most current version (2.0, published 2017). Furthermore, a longitudinal comparison within this patient cohort was not possible, as we only had one time point to perform the planned examinations.

In this cross-sectional study, we have succeeded in performing quality control of our oncoplastic breast surgery program in a large cohort since 2010. We generally received favorable PRO scores in both the BIS and BreastQ subitems compared to international data. Oncoplastic surgery is well accepted in patients with breast cancer and correlates with high patient satisfaction.

The study was approved by the Ethical Review Board of the Medical University of Vienna, decision Nr. 1236/2019. All patients were informed about the study design and signed an informed consent form.

The authors have no conflicts of interest to declare.

The authors did not receive any funding. This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

M.B.: writing of the manuscript, statistics, planning and supervision of the study. L.G., T.H., and F.M.: collection of patient data and performing the study. S.K.: reviewing statistics and manuscript and correction of the manuscript. F.F.: planning and supervision of the study and correction of the manuscript.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.