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2 BREAST Outcomes Article Oncoplastic Breast Surgery for Cancer: Analysis of 540 Consecutive Cases Alfred D. Fitoussi, M.D. M. G. Berry, M.S., F.R.C.S.(Plast.) Fausto Famà, M.D. Marie-Christine Falcou, B.Sc. Alain Curnier, F.R.C.S.(Plast.) Benoit Couturaud, M.D. Fabien Reyal, M.D. Remy J. Salmon, M.D., Ph.D. Paris, France Background: Synchronous plastic and oncological surgery is undertaken to improve the security of excision margins and yield high-quality aesthetic outcomes when conventional breast-conserving therapy either anticipates poor results or is not possible. Methods: A total of 540 consecutive patients underwent primary oncoplastic breast surgery for cancer with high tumor-to-breast volume ratios and locations precluding a good aesthetic result with simple tumor excision. A variety of techniques were employed at the Institut Curie between 1986 and 2007, and aesthetic outcomes were assessed on a five-point scale from 1 (excellent) to 5 (poor). Results: The median age was 52 years (range, 28 to 90 years), and median follow-up was 49 months (6 to 262 months). Median tumor size was 29.1 mm (range, 4 to 100 mm), with most patients (72.3 percent) having a brassiere cup size of B or C. Close or involved margins occurred in 18.9 percent, with mastectomy being necessary in 9.4 percent. A satisfactory aesthetic outcome (ratings of 1 to 3) at 5 years was obtained in 90.3 percent. Five-year overall and distant disease-free survival rates were 92.9 and 87.9 percent, respectively, with local recurrence in 6.8 percent. Conclusions: With local recurrence and survival rates similar to those for breastconserving therapy, this series confirms the safety of oncoplastic breast surgery for tumors both high in volume and difficult in location. Highly satisfactory cosmetic outcomes extend the indications for conservative surgery, further reduce the mastectomy rate, and limit adverse aesthetic sequelae. (Plast. Reconstr. Surg. 125: 454, 2010.) The shift from radical surgical ablation to conserving treatment for breast cancer was actually led by radiotherapists, 1,2 with surgical intervention being added much later. 3 For small ( 2 cm) and node-negative tumors, however, Veronesi et al. deserve credit for the first randomized trial proving safe submastectomy surgery. 4 Further studies, with larger ( 4 cm) tumors, 5 confirmed that equivalent overall and disease-free survival to mastectomy could be produced by tumorectomy combined with radiotherapy: this has come to be known as breast-conserving therapy. Time has, however, shown that standard breast-conserving therapy has its limits and may yield poor cosmetic results in as many as 20 to 30 From the Departments of Surgery and Biostatistics, Institut Curie. Received for publication April 9, 2009; accepted August 4, Presented at the inaugural Oncoplastic and Reconstructive Breast Surgery meeting, in Nottingham, United Kingdom, June of Copyright 2010 by the American Society of Plastic Surgeons DOI: /PRS.0b013e3181c82d3e percent 6,7 when initial suboptimal surgical results are invariably worsened by irradiation. Correction of such cosmetic deformities requires challenging surgery in operated and irradiated tissues, the results of which may be unpredictable. 8,9 Oncoplastic breast surgery was therefore developed to anticipate and ameliorate these poor outcomes at the time of the oncological surgery. Prolonged survival in breast cancer, coupled with rising patient expectation, has focused attention on the aesthetic result in addition to satisfactory oncological management. While some have examined the relationship between excision weight and aesthetic outcome, 10 a simpler concept is tumor excision in proportion to breast volume. Cochrane et al. showed that approximately 10 percent was an upper resection limit, with less tolerance medially due to the relative paucity of tissue. 11 Pioneers, such as Clough, Disclosure: The authors have no financial interest to declare in relation to the content of this article

3 Volume 125, Number 2 Oncoplastic Breast Surgery indicate that up to 20 percent volume excisions may yield satisfactory results, but some form of local parenchymal rearrangement or excess skin excision is generally required. 12 Oncoplastic breast surgery emerged to address subsequent levels and further reduce indications for mastectomy. Although coined in 1998, 13 the first study of lower pole tumors appeared in in which the breast reduction excision included tumor excision: this became the progenitor oncoplastic breast surgery technique in several countries. 8,15 17 Along with tumor volume, another fundamental factor is tumor location, and the recent literature has seen reports of techniques both transferred from aesthetic surgery and those specifically created for the oncological resection, particularly in central tumors Having been involved in breast-conserving therapy in the 1970s and the birth of oncoplastic breast surgery in the 1980s, the Institut Curie has amassed a wealth of practical experience and developed a range of novel techniques to suit all tumors. Although some are standard aesthetic surgery techniques applied in the cancer setting, others are oncological procedures combined with well-proven plastic surgery principles specifically designed to minimize postoperative deformities. This consecutive study of 540 patients from a single center confirms the oncological safety of oncoplastic breast surgery over time without compromising the quality of the aesthetic outcome. PATIENTS AND METHODS The study population involved 540 consecutive patients who underwent oncoplastic breast surgery for breast cancer between 1986 and 2008 for either tumor volume or location considerations. Standard oncological parameters, including overall (i.e., alive) and disease-free (i.e., alive but with recurrent disease) survival and local (i.e., ipsilateral breast) recurrence, were collated and surveillance was assessed by individual record review. A five-point grading system of aesthetic outcome involving three different individuals, including the surgeon, a nurse, and layperson, has been in operation at the Curie for many years as previously reported 15 : 1, excellent; 2, good; 3, satisfactory; 4, mediocre; and 5, poor, with a representative example of each being shown in Figure 1. For ease of presentation, the five-point outcome scale has been dichotomized so that grades 1 to 3 are considered good and 4 to 5 poor. The particular surgical technique was selected according to the tumor volume and location. The Cox proportional hazards model was used to perform statistical analysis of the endpoints (local recurrence, distant disease-free, and overall survival). Survival curves were evaluated with Kaplan-Meier estimation and log-rank tests using the computer program R version In accordance with convention, a p value less than 0.05 is considered significant. RESULTS Patient and Tumor Demographics The median age was 52 years (range, 28 to 90 years), with a median follow-up of 49 months (range, 6 to 262 months), reflecting the progressive increase in oncoplastic breast surgery as shown in Figure 2. The median body mass index was 23.6 (range, 6.6 to 47.2), and brassiere cup size distribution is summarized in Figure 3. A total of 248 patients were premenopausal, and 29 and 15 had a history of contralateral and ipsilateral breast cancer, respectively. A total of 317 (58.7 percent) were diagnosed radiographically, and 11 presented with synchronous contralateral cancer. The majority, 460 (85.2 percent), were unifocal, with a mean tumor size of 29.1 mm (range, 4 to 100 mm), with American Joint Committee on Cancer tumor-node-metastasis staging as shown in Table 1. A total of 108 patients (20 percent) were administered neoadjuvant therapy (Table 2), which reduced the median tumor size to 25 mm (0 to 60 mm), with 15 having a complete response with no tumor remaining for evaluation. The preoperative and definitive histopathological diagnoses are shown in Table 3. Surgical Techniques There were a variety of techniques utilized, broadly divided into aesthetic (i.e., those with otherwise standard aesthetic surgical techniques) and combination, in which oncological excisions were modified with plastic surgical principles as detailed in Table 4. The prime indication for oncoplastic breast surgery was found to be tumor location, either alone or in combination with volume, with distribution as detailed in Figure 4. Patients underwent axillary surgery (dissection or sentinel node biopsy) according to institutional protocols in 79.2 percent, with 31.3 percent accessed through the oncoplastic breast surgery incision. The mean resection weight was 187.7g (range, 8 to 1700 g), and the mean inpatient stay was 4.7 days (range, 1 to 13 days). 455

4 Plastic and Reconstructive Surgery February 2010 Fig. 1. Representative examples of aesthetic grading: (above, left) 1, excellent; (above, right) 2, good; (center, left) 3, satisfactory; (center, right) 4, mediocre; (below) 5, poor. Immediate symmetrization was performed in 46.1 percent overall, with a marked difference between the first and second halves of the study period (Fig. 5). The mean excision weight was g. 456 Outcomes Clear margins were obtained in 438 patients (81.1 percent), with a median excision margin of 10 mm (range, 1 to 50 mm). Of the 102 positive margins, 77 were focal (defined as ⱕ 1 mm) and

5 Volume 125, Number 2 Oncoplastic Breast Surgery Fig. 2. Annual frequency of oncoplastic breast surgery. Fig. 3. Distribution of brassiere cup sizes. Table 1. Staging According to the American Joint Committee on Cancer Classification of Malignant Tumors (2002)* Stage No. of Patients Stage Stage I 126 Stage IIA 176 Stage IIB 84 Stage IIIA 17 Stage IIIB 9 Stage IIIC 1 Total 536 *Classification was not possible in four cases. Table 2. Summary of Neoadjuvant Therapy No. Chemotherapy 93 Hormone therapy 12 Radiotherapy ( chemotherapy, hormone therapy) 14 Total were diffuse ( 1 mm). Eleven patients underwent repeated local excision, 40 had a radiotherapy boost (of 10 Gy), and 51 (9.4 percent overall) had a mastectomy, as detailed in Figure 6. With respect to 5-year survival, the rates for overall and disease-free survival were 92.9 and 87.9 Table 3. Histopathological Diagnosis Preoperatively and Postoperatively Preoperative (%) Postoperative (%) Invasive ductal Ductal carcinoma in situ Invasive lobular Lobular carcinoma in situ Paget disease Other Nil 4.8* *No residual tumor was identified following neoadjuvant therapy. percent, respectively. Local recurrence was observed in 6.8 percent. With regard to the aesthetic evaluation, 97.7 percent were considered to have achieved a good result at 12 months, and by 5 years, this had stabilized at 90.3 percent. Revisional surgery for aesthetic reasons was undertaken in 42 patients (7.8 percent), one of whom had a further revision. Overall, complications were seen in 16.3 percent (62 early and 25 late) as tabulated (Table 5), but surgical intervention was required in only 18 cases (3.3 percent), with three of them on the 457

6 Plastic and Reconstructive Surgery February 2010 Table 4. Summary of Surgical Techniques Used in This Study Technique No. (%) Aesthetic Inverted-T (superior pedicle) 192 (35.6) Vertical 37 (6.8) J-plasty 59 (10.9) Periareolar 36 (6.7) Inverted-T (inferior pedicle) 26 (4.8) Other 7 (1.3) 357 (66.1) Combination Lateral mammaplasty 111 (20.6) Omega 30 (5.5) Inframammary fold plasty 12 (2.2) Nipple-areola complex excision 27 (5) Medial mammaplasty 3 (0.6) 183 (33.9) Fig. 4. Tumor distribution by percentage. The solid circle represents central tumors 2 cm from the nipple mandating excision. The dashed circle represents central tumors not requiring nipple excision. The asterisk (*) indicates those located at the inframammary fold. contralateral breast. The remainder were managed conservatively. Importantly, complications delayed adjuvant therapy in only 10 patients (1.9 percent). DISCUSSION Being a recent addition to the breast cancer armamentarium, oncoplastic breast surgery publications have hitherto arisen from those with a particular interest, thus relatively small series 16,20,21 or technical descriptions 18,19,22 are the norm. Longterm cancer surveillance data and aesthetic evaluation are presently lacking. Our unit commenced oncoplastic breast surgery in the late 1980s and has accrued a body of experience that started with the prototypical inverted-t breast reduction pattern but now encompasses a range of techniques that address all tumors suitable for attempted breast-conserving surgery. If oncological parameters are similar to those established by breast-conserving therapy, breast conservation can be extended beyond the current levels of 70 percent. Indications for mastectomy may now be limited to T4 and inflammatory tumors, widespread ductal carcinoma in situ/extensive malignant microcalcification, multicentric disease, and other situations in which clear margins can only be assured with mastectomy. 23 With simple excision sufficing for tumors up to 10 percent volume 11 andthoseupto20percent with some degree of local parenchymal rearrangement, 12 oncoplastic breast surgery should therefore be considered for tumor-tobreast volume ratios in excess of 15 to 20 percent. This is, of course, merely a guide and oncoplastic breast surgery should also be considered in its other chief guise for difficult tumor locations, such as the inferior quadrants, for which poor results are twice as likely, 24 centrally, superomedially, and in the inframammary fold. There are now strong data from a randomized 20-year follow-up that confirm the equivalence of breast-conserving therapy to mastectomy with respect to overall and disease-free survival. 25,26 These and other studies have established a benchmark for ipsilateral breast recurrence against which any new technique may be measured. A rate around 7.7 percent has been reported at 5 percent and 12 to 18 percent at 10 years. 3,27 These early studies involved T1-T2 tumors (up to 5 cm) so our rate of 6.8 percent, including stage III tumors, appears acceptable. Although oncoplastic breast surgery procedures have been performed for more than 20 years at our institution, the majority, as shown in Figure 1, have been performed over the last few years, so the 10-year data are statistically immature. Overall and distant disease-free 5-year survival rates of 92.9 and 87.9 percent also appear acceptable with reference to the literature. 4,5,28 The only oncoplastic breast surgery study comparable to ours comes from the Milan unit, which has followed 148 patients for 6 years. 21 There are some differences, including a smaller mean tumor diameter of 22 mm and the use of prostheses and musculocutaneous flaps for large defects (indicating a degree of excisional radicality), but they 458

7 Volume 125, Number 2 Oncoplastic Breast Surgery Fig. 5. Rate of synchronous symmetrization surgery representing annual proportions illustrating how the initial ubiquity diminished markedly in the second half of the study period. Fig. 6. Fate of incomplete excision margins following primary oncoplastic breast surgery. Of those with involved margins, one-half were managed satisfactorily by either a repeated oncoplastic breast surgery or radiotherapy, with the other half requiring mastectomy (focal, 1 mm; diffuse, 1 mm). experienced ipsilateral recurrence in 3 percent, with overall and distant disease-free survival of 92.5 and 87 percent, respectively. 21 Incomplete margins represent failure of breast-conserving therapy and have been treated in different ways, with Fisher et al. s group allowing only a single attempt before proceeding to mastectomy, hence the rate of 10 percent. 5 Jacobson et al. took a different view and had a mastectomy rate of 0.83 percent after two excisions. 27 Although their local recurrence rate, at 18 percent, was much higher at 10 years, the tumors were larger, so direct comparisons are not easy. For oncoplastic breast surgery, the Milanese achieved 91 percent complete excision but proceeded to mastectomy in only a single patient, with the remaining 12 patients being simply placed under surveillance. 21 Again, our study drew from a wide population in terms of tumor size, so the rate (9.4 percent) being in the upper range is perhaps not 459

8 Plastic and Reconstructive Surgery February 2010 Table 5. Summary of Postoperative Complications* Complication Ipsilateral Contralateral Surgery Early Delayed healing 15 1 Hematoma Seroma 5 Abscess 5 3 Cutaneous necrosis Nipple-areola complex necrosis Other * 7 18 (3.3%) Late Scar fibrosis 10 Hypertrophic scarring 8 Steatonecrosis 4 Pain 3 25 (4.6%) *There were a further eight axillary seromata treated nonsurgically and an unexplained pyrexia, for 62 early complications overall. wholly surprising. It is important to note that despite involved margins, mastectomy is not obligatory, as one-half of this group was satisfactorily managed oncologically with either repeated oncoplastic breast surgery or radiotherapy boost. Interestingly, when analyzed for any learning curve, it was found that there was a difference in the incomplete excision rates between the first and second halves in favor of the former. This can be explained by two factors: the first that progressively larger tumors have been attempted with passing time. Second, the more challenging locations, central, superomedial, and so forth, have been subjected to oncoplastic breast surgery. It is worth reiterating that our patients were selected for oncoplastic breast surgery because of high tumor-to-breast volume ratios, difficult locations, or multifocality, rendering breast-conserving therapy difficult. Furthermore, the techniques are novel, so conventional boundaries have expanded. Although there are several advantages to the present study, including its consecutive nature, large numbers, and single institution, there are disadvantages, such as the evolutional nature of the practice and retrospective character of the study. Experiential evolution has left us 10 techniques now in regular utilization, with each being adapted primarily for tumor location. The inverted-t breast reduction pattern is now well-established in oncoplastic breast surgery and other aesthetic breast surgery procedures: vertical scar, J-mammaplasties, L-mammaplasties, and periareolar/round block 29 are well-known to plastic surgeons. The combination techniques are in essence wide tumorectomies but with the incorporation of plastic surgical principles, such as nipple-areola complex repositioning to reform the aesthetic breast triangle 30,31 ; and early analyses of individual techniques are starting to appear (e.g., lateral mammaplasty and the omega-plasty). 32 Briefly, the lateral mammaplasty combines wide, triangular, en bloc excision of skin and parenchymna around laterally based tumors. Because reconstitution reduces the breast mound diameter, the nipple-areola complex requires elevation and medial transposition: this is based on a dermoglandular pedicle as recently described. 33 Omega-plasty is ideal for superomedial tumors in ptotic breasts. The excision skirts the superior nipple-areola complex border in the form of a batwing, and the Institut Curie s experience was reported recently. 34 Axillary surgery is an important component of mammary oncology, and some may have concerns about further incisions. In fact, in 31.3 percent of our cohort, a common incision was used, sparing the patient further scarring. In the remaining 68.7 percent, the separate incision produced no oncoplastic flap viability problems. There may be reluctance to introduce oncoplastic breast surgery because of a fear of increased complications from the technically more difficult surgery and consequent delay in adjuvant therapy. In fact, our overall rate of 11.5 percent is not dissimilar to that in the aesthetic breast surgery literature, 35 and only 3.3 percent required further surgical intervention, which produced a delay in the start of adjuvant therapy in less than 2 percent. One of the originally stated benefits of oncoplastic breast surgery was its ability to address a key component of breast aesthetics, namely symmetry. Although this was systematically performed synchronously in the early years, a shift has occurred (Fig. 5) so that it is now most unusual. Although it might appear efficacious, the effects of adjuvant radiotherapy are unpredictable, but the natural aging and ptosis of the treated breast are certainly limited. Moreover, although not specifically addressed in this study, we have observed that overall body weight tends to fluctuate in breast cancer patients in relation to diagnosis, surgery, and adjuvant therapy, particularly chemotherapy. Symmetrization is now generally undertaken 6 months after the cessation of treatment. As has already been noted, aesthetic results are substantially worse if irradiation precedes surgery, 15,24 and this practice has been abandoned. Contemporaneous patients are no longer satisfied merely with retaining some part of the native breast, no matter what its appearance, and plastic surgery is a natural and logical addition to breast cancer management. With a mean age of diagno- 460

9 Volume 125, Number 2 Oncoplastic Breast Surgery sis in the 50s, many patients actually have aesthetic concerns preoperatively with postpartum ptosis being common and so appreciate the added benefit that oncoplastic breast surgery may give to their oncological treatment. Standard breast-conserving therapy led to poor aesthetic outcomes in 20 to 30 percent, 6,7 but a recent report has shown that rates below 7 percent can be achieved at 2 years with the incorporation of oncoplastic breast surgery techniques. 36 In fact, this figure is echoed by our own of 6.7 percent at 2 years, so it would appear to represent the contemporaneous benchmark. CONCLUSIONS The incorporation of plastic surgery into oncological breast cancer treatment appears acceptable oncologically (for local recurrence, overall, and distant disease-free survival), surgically (low complication, surgical revision and adjuvant therapy delay rates), and is beneficial aesthetically. It allows tumor-specific, tailored surgery that improves the care and outcomes for breast cancer patients. M. G. Berry, M.S., F.R.C.S.(Plast.) Departement de Chirurgie 25 rue d Ulm, Institut Curie Paris 75005, France militorum@hotmail.com ACKNOWLEDGMENTS The authors thank K. B. Clough, C. Nos, H. Charitansky, and M. Ballester for their surgical contribution, V. Mosseri for her invaluable technical assistance, and the Breast Group at the Institut Curie (coordinator B. Sigal-Zafrani). REFERENCES 1. Keynes G. The place of radium in the treatment of cancer of the breast. Ann Surg. 1937;106: Baclesse F, Gricouroff G, Tailhefer A. Essai de roentgenthérapie du cancer du sein suivie d opération large: Résultats histologiques. Bull Cancer 1939;28: Calle R, Pilleron JP, Schlienger Vilcoq JR. Conservative management of operable breast cancer. Cancer 1978;42: Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med. 1981;305: Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985;313: Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V. Cosmetic sequelae after conservative treatment for breast cancer: Classification and results of surgical treatment. Ann Plast Surg. 1998;41: D Aniello C, Grimaldi L, Barbato A, Bosi B, Carli A. Cosmetic results in 242 patients treated by conservative surgery for breast cancer. Scand J Plast Reconstr Hand Surg. 1999;33: Berrino P, Campora E, Santi P. Postquadrantectomy breast deformities: Classification and techniques of surgical correction. Plast Reconstr Surg. 1987;79: Clough KB, Thomas S, Fitoussi AD, Courturaud B, Reyal F, Falcou M-C. Reconstruction after conservative treatment for breast cancer: Cosmetic sequelae classification revisited. Plast Reconstr Surg. 2004;114: Petit JY, Rietjens M, Garusi C, Perry C. Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve cosmetic results and radicality of tumour excision. Recent Results Cancer Res. 1998;152: Cochrane RA, Valasiadou P, Wilson ARM, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg. 2003;90: Clough KB. Keynote speech: Oncoplastic surgery. Presented at the RACS/CSHK Conjoint Annual Scientific Congress, Hong Kong, May Audretsch W, Rezai M, Kolotas C, et al. Tumour-specific immediate reconstruction in breast cancer patients. Perspect Plast Surg. 1998;11: Clough KB, Soussaline M, Campana F, Salmon RJ. Combination mammaplasty-radiotherapy: Conservative treatment for breast cancers localised to the lower quadrants. Ann Chir Plast Esthet. 1990;35: Clough KB, Nos C, Salmon RJ, Soussaline M, Durand J-C. Conservative treatment of breast cancers by mammaplasty and irradiation: A new approach to lower quadrant tumors. Plast Reconstr Surg. 1995;96: Losken A, Elwood ET, Styblo TM, Bostwick J III. The role of reduction mammaplasty in reconstructing partial mastectomy defects. Plast Reconstr Surg. 2002;109: McCulley SJ, Macmillan RD. Therapeutic mammaplasty: Analysis of 50 consecutive cases. Br J Plast Surg. 2005;58: McCulley SJ, Durani P, Macmillan RD. Therapeutic mammaplasty for centrally located breast tumors. Plast Reconstr Surg. 2006;117: Huemer GM, Shrenk P, Moser F, Wagner E, Waynard W. Oncoplastic techniques allow breast-conserving treatment in centrally located breast cancers. Plast Reconstr Surg. 2007;120: Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou M-C. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Ann Surg. 2003;237: Reitjens M, Urban CA, Rey P, et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007;16: McCulley SJ, Macmillan RD. Planning and the use of therapeutic mammaplasty: Nottingham approach. Br J Plast Surg. 2005;58: Association of Breast Surgery at BASO. Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol. 2007;33: S1 S Nos C, Fitoussi A, Bourgeois D, Fourquet A, Salmon RJ, Clough KB. Conservative treatment of lower pole breast cancers by bilateral mammoplasty and radiotherapy. Eur J Surg Oncol. 1998;24: Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:

10 Plastic and Reconstructive Surgery February Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347: Jacobson JA, Danforth DN, Cowan K, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med. 1995;332: Blichert-Toft M, Rose C, Andersen J, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: Six years of life-table analysis. J Natl Cancer Inst Monogr. 1992;11: Benelli L. A new periareolar mammaplasty: The roundblock technique. Aesthet Plast Surg. 1990;14: Penn J. Breast reduction. Br J Plast Surg. 1955;7: Westreich M. Anthropomorphic breast measurement: Protocol and results in 50 women with aesthetically perfect breasts and clinical application. Plast Reconstr Surg. 1997;100: Christiansen D, Kazmier FR, Puckett CL. Safety and aesthetic improvement using the omega pattern reduction mammaplasty after breast conservation surgery and radiation therapy. Plast Reconstr Surg. 2008;121: Berry MG, Ballester M, Fitoussi A, Couturaud B, Salmon RJ. Lateral mammaplasty for oncoplastic breast surgery. Eur J Surg Oncol. 2008;34: Curnier A, Berry MG, Couturaud B, Fitoussi A, Salmon RJ. Omegaplasty for breast cancers of the superior and superomedial quadrants. Presented at the British Association of Plastic Reconstructive and Aesthetic Surgeons Scientific Meeting, Leeds, United Kingdom, July Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas DA. Reduction mammaplasty with the inferior pedicle technique: Early and late complications in 371 patients. Br J Plast Surg. 1996;49: Munhoz AM, Montag E, Arruda E, et al. Assessment of immediate conservative breast surgery reconstruction: A classification system of defects revisited and an algorithm for selecting the appropriate technique. Plast Reconstr Surg. 2008; 121: Submit your manuscript today through PRS Enkwell. The Enkwell submission and review Web site helps make the submission process easier, more efficient, and less expensive for authors, and makes the review process quicker, more accessible, and less expensive for reviewers. If you are a first-time user, be sure to register on the system. 462