Oncoplastic surgery is not an absolute guarantee of good cosmetic results, and the onset of sequelae during its follow-up is an uncomfortable truth that we need to accept. The introduction of oncoplastic procedures by the end of the 1990s attempted to alleviate the cosmetic sequelae of lumpectomy, especially in the resection of the lower pole and in multifocal processes. As with lumpectomies, oncoplastic surgery shares the same conflicts of interest between the cancer criteria (maximum tumor resection) and cosmetic criteria (minimal breast removal), as well as the cosmetics changes resulting from unilateral breast irradiation. It is understandable that after the initial stage of excitement due to the introduction of these breast surgery procedures (whose potential and advantages we have praised), there is a self-criticism stage to assess their oncological and cosmetic results. This new self-criticism stage will help limit the overindication of oncoplastic procedures and define the patient profile that will gain benefits from the use of these procedures in oncologic terms and in terms of satisfaction.
We currently have no studies that have analyzed the progression of cosmetic sequelae during follow-up, which precludes a comparison of our results. Our study shows that most cosmetic sequelae occur during the first 5 years and subsequently stabilize during the follow-up.
Various factors can be involved in this plateau phase; however, the 2 determinants in this event are probably the completion of the antihormonal therapy and the deceleration of the effects of breast irradiation. The progression during the follow-up varies for each type of sequela. Thus, the earliest sequelae are the deformities because they reflect an anatomical defect directly related to the capacity for reshaping and to the effects of the radiation therapy. This close relationship between anatomy and radiation therapy explains why, in our experience, 86% of the deformities manifest during the first 3 years of follow-up. Furthermore, our study reflects that the main cause of a deformity is insufficient reshaping of the anatomical defect, either during the initial surgery, during margin expansion or after a local complication (seroma, hematoma). This conflict becomes clearer in level 1 oncoplastic surgery because the capacity for reshaping is more limited and explains why 80% of the sequelae in this group are deformities. Nevertheless, the onset of deformities is also high in patients who undergo level 2 procedures, especially in extreme oncoplasty, because these cases are characterized by greater anatomical resection, greater technical complexity and higher incidence of complications. These characteristics also explain the higher rate of fat necrosis in level 2 oncoplasty, which in turn is the cause of deformity in certain patients.
Asymmetry is an event that presents a progression and origin different from that of deformities. There are 2 different profiles for the onset of asymmetry depending on its cause. The first group consists of patients who have not undergone symmetrization during horizontal or vertical mammoplasty. Most of these patients experienced asymmetry in breast shape, not size, and the asymmetry occurs immediately after the surgery. In contrast, there is another patient group for whom the asymmetry occurs later during the follow-up and, in most cases, reflects the double effect of adjuvant therapies. This double effect is characterized by a size reduction in the irradiated breast, by its progressive fibrosis and by an increase and ptosis in the opposite breast due to changes in the body mass index, generally in women undergoing antihormonal therapy. This sequela is common to all conservative surgery and occurs in women with symmetrization of the opposite breast. It is therefore important to incorporate this information in the shared decision making of level 2 oncoplastic surgery to properly warn patients that the performance of the healthy breast is not an absolute guarantee of symmetry during the follow-up. Asymmetries are better tolerated by patients than deformities, possibly because asymmetries have a gradual onset. In our experience, few patients opt to correct the asymmetry once the antihormonal therapy has been completed.
Lastly, type III sequelae are uncommon events and occur later during the follow-up. Radiotherapy optimization has reduced the rate of extreme radiodermatitis in the breast volume, and the onset of radiodermatitis reflects in considerable measure the individual’s susceptibility to radiation’s toxic effects. In contrast, the presence of extensive fat necrosis after breast irradiation is related to the surgical procedure and breast type. Thus, 2 of our postmenopausal patients with breast fat with this cosmetic sequela had undergone oncoreductive mammoplasty.