Abstract
Purpose
The use of advanced energy devices for mastectomy and axillary lymph node dissection can reduce perioperative blood loss, seroma formation, and drainage duration/volume. Retraction using fiberoptic retractors can help visualize deep and narrow surgical fields. We aimed to compare the postoperative outcomes between single-incision breast-conserving surgery (SIBCS) and conventional breast-conserving surgery (CBCS) with axillary staging using advanced energy devices and conventional equipment, respectively.
Materials and Methods
We retrospectively reviewed the medical records of 244 patients who underwent BCS with axillary surgery between March 2018 and September 2019 at Severance Hospital. The patients were grouped based on the device used to aid in axillary staging: CBCS group (n=117) used conventional electrocautery; and SIBCS group (n=127) used advanced energy devices and fiberoptic retractors. The two groups were compared for postoperative outcomes.
Results
The mean patient age was 55.9 and 53.1 years in the CBCS and SIBCS groups, respectively. Incision size was significantly smaller in the SIBCS group than in the CBCS group (6.3±2.1 cm vs. 7.5±2.5 cm, p=0.044). There were no significant differences between the two groups in terms of operating time (126.0±40.0 min vs. 127.0±63.0 min, p=0.828), operative blood loss (11.0±31.0 mL vs. 7.0±18.0 mL, p=0.100), drainage duration (7.0±3.0 d vs. 8.0±4.0 d, p=0.288), and complications (1.70% vs. 2.36%, p=0.523).
Conclusion
Using advanced energy devices for SIBCS with axillary staging reduced incision size and provided better cosmetic outcomes compared to those using the conventional method. Advanced energy devices may offer better surgical outcomes in patients who undergo BCS with axillary staging.
Keywords: Segmental mastectomy, breast neoplasm, surgical instruments, minimally invasive surgical procedures/instrumentation, minimally invasive surgical procedures/methods, surgical wound
Graphical Abstract
INTRODUCTION
Breast-conserving surgery has become the standard surgery for early breast cancer, with equivalent rates of local control and overall survival and lower complication rates than mastectomy demonstrated in many trials.1,2,3,4,5 Additionally, sentinel lymph node biopsy (SLNB) has been proven as effective as axillary node dissection for evaluating nodal staging in large randomized controlled trials.6
However, the standard BCS with SLNB usually requires two incisions. One incision is to remove the tumor and the other is to obtain lymph nodes. Even in conventional surgery, there are cases where one incision surgery is possible, but it is limited by the location and the distance from the nipple. These additional incisions are often associated with cutaneous devascularization and distortion of the breast tissue that adversely affect the cosmetic outcomes. Several studies have shown that cosmetic results after breast cancer surgery affect women, their body image, and sexual function, and can also have a significantly negative effect on the quality of life.7,8,9 Therefore, satisfying the patient need for cosmesis has also become an important issue.
Various surgical methods have been devised to satisfy the needs of these patients without oncological complications. As a part of such efforts, the concept of oncoplastic surgery has emerged. Although endoscopic-assisted breast surgery provides better cosmesis than conventional surgery, it has disadvantages, including a higher physical demand on surgeons. Long rigid instruments used in endoscopic-assisted breast surgery have a longer learning curve than conventional instruments. Lack of training and information about the use of these devices is also one of the hurdles in the wider implementation of endoscopic-assisted breast surgery. It is possible that the limited use of endoscopic breast surgery is related to the longer learning curve and limitations of current endoscopic instruments.10
Advanced energy devices can be used to reduce incision and improve cosmetic outcomes in BCS. Advanced energy devices, such as Harmonic Scalpel (Johnson & Johnson MedTech, New Brunswick, NJ, United States), LigaSure (Medtronic, Minneapolis, MN, United States), and Thunderbeat (Olympus, Tokyo, Japan) have shown superior outcomes in terms of intraoperative blood loss, postoperative drainage output, and postoperative seroma incidence compared to conventional methods.11 To date, cosmetic outcomes after BCS using advanced energy devices have not been extensively studied. The inconspicuous peri-areolar incision in BCS can also be performed with tumor resection, but this method can be performed only in selected patients with tumors located in the peri-areolar area.
Handheld lighted fiberoptic retractors (Electronic Surgical Instrument Company, New York, NY, USA) can be used in various surgeries, such as facial, plastic, nasal, and general surgeries. Fiberoptic retractors are particularly used in minimally invasive surgery due to better visualization in deep and narrow operative fields.12 However, the use of fiberoptic retractors in BCS is not well-established.
The current study introduced BCS with axillary staging via a single-incision using advanced energy devices and handheld fiberoptic retractors. Additionally, we aimed to assess the use of a peri-areolar single-incision approach for BCS using advanced energy devices and handheld fiberoptic retractors to determine its impact on the success of tumor resection and perioperative outcomes compared to that of CBCS.
MATERIALS AND METHODS
Data collection
We retrospectively analyzed data from the medical records of patients who underwent BCS with axillary staging for treatment of breast cancer by experienced breast surgeon at Severance Hospital between March 2018 and September 2019. The surgeon in this study has had more than 10 years of breast cancer surgery experience and has performed about 300 cases of breast cancer surgery per year. Information extracted included patient age, body mass index, pathological findings, type of surgery, surgical instruments used, operation time, perioperative blood loss, drainage duration/volume, and postoperative complications.
Medical records of 302 patients were considered. Patients who underwent BCS and cases in which partial mastectomy without axillary surgery were performed were excluded. In addition, cases of certain tumor types, such as lobular carcinoma in situ and malignant phyllodes tumor rather than invasive ductal carcinoma and ductal carcinoma in situ, were also excluded from the data. The data was extracted as BCS; however, there was one case in each group where the surgery name was incorrect, so it was excluded. After application of these criteria, 58 patients were excluded. A total of 244 patients were finally enrolled in the study (Fig. 1).
Fig. 1. Data from the medical records of patients who underwent BCS with axillary staging for treatment of breast cancer by a breast surgeon at Severance Hospital between March 2018 and September 2019 were collected. Records of 302 patients were considered. Exclusion criteria included patients who received only partial mastectomy without axillary staging and special type, such as LCIS or phyllodes tumor. After the application of these criteria, 58 patients were excluded. A total of 244 patients were finally enrolled in the study. CBCS, conventional breast-conserving surgery; SIBCS, single-incision breast-conserving surgery; LCIS, lobular carcinoma in situ.
The SIBCS group consisted of 127 patients who underwent BCS with advanced energy devices and fiberoptic retractors, while the CBCS group consisted of 117 patients who underwent BCS using conventional instruments, such as Bovie mono-electrocautery and tie ligation. CBCS was performed using non-fiberoptic retractors, such as Richardson and/or Army-Navy retractors.
This study was approved by the Institutional Review Board (IRB) of Severance Hospital, Seoul, Republic of Korea (4-2020-1440).
Outcomes
The surgeon marked the planned incision with a pen, and the incision size was checked using a ruler before cutting. Operative time (min) was calculated from the initial skin incision to the closure of the breast skin. The total drainage duration/volume until removal of surgical drain were obtained from medical records. The drain was removed when the volume was less than 20 mL/day. Both groups were analyzed for their clinical characteristics, postoperative outcomes (e.g., incision size, operation time, operative blood loss, and drainage volume and duration), postoperative complications within 1 month [e.g., nipple-areolar complex (NAC) ischemia, surgical site infection, and wound dehiscence], and the assessment of their satisfaction using the BREAST-Q questionnaire. The BREAST-Q is a developed patient-reported outcome measure designed to evaluate the outcomes among women undergoing different types of breast surgery. The Breast-Conserving Therapy Module was selected for this study. This module is divided into quality of life and satisfaction domains. In the quality-of-life domain, “psychosocial well-being” and “physical well-being: chest” were selected, and in the satisfaction domain, “satisfaction with breasts” was selected. A questionnaire was provided to 30 patients who visited the outpatient clinic 2 years after surgery, and the questionnaire was scored according to the method provided by BREAST-Q. A total of 30 patients were surveyed.
Statistics
Data were analyzed using SPSS statistics (version 24.0.0.0; IBM Corp., Armonk, NY, USA). Continuous variables were presented as means±standard deviations, and categorical variables were presented as numbers with percentages. Continuous variables were analyzed using the t test, and categorical variables were compared using the chi-square test. Differences were considered statistically significant at p-value<0.05, two-sided.
Procedures
CBCS
The location of the incision differed depending on the quadrant occupied by the tumor. If the tumor was close to the upper quadrant of the breast, an incision was made in the axilla, which allowed both the tumor and axillary lymph nodes to be removed in a single incision. If the tumor located in one of the other quadrants, an incision was made in the skin above the tumor. An additional axillary incision was required for axillary staging. After the specimen was extracted, the surgical site was marked with surgical clips for future radiotherapy.
SIBCS
There were three types of energy devices used in SIBCS: Harmonic Scalpel, LigaSure, and Thunderbeat. Each device was selected randomly by the surgeon, and the device was not selected according to the difficulty of the case.
The advanced energy device-assisted surgery was performed with a peri-areolar or round-block incision regardless of the tumor location. Unless an axillary dissection was required, the surgery was performed using a single incision.
The single-incision BCS approach begins with the patient in the supine position, and the ipsilateral arm extended over the head to expose the wire-localized tumor and axilla. Sentinel lymph nodes are identified using intraoperative peri-areolar injection of the dye. A single incision is made in the peri-areolar region. With good retraction using fiberoptic retractors, a plane between the breast tissue and subdermal fat can be visualized, and dissection is carried out in this plane to ensure removal of all possible breast tissues while maintaining the viability of the skin. The fiberoptic retractors secure a field of view, and the surgeon can operate with a single incision (Fig. 2A). A blue-dyed lympn node (LN) is visible in the middle of the operation field. The blue dyed LN is approached using a long-body energy device while retracting with fiberoptic so that the deep operating field can be clearly seen (Fig. 2B).
Fig. 2. Procedure using fiberoptic retractors via the single periareolar incision. (A) Fiberoptic retractors provide better visualization in deep and narrow operative fields. (B) A blue-dyed LN is visible in the middle of the operation field. The blue-dyed LN is approached using a long-body energy device while retracting with fiberoptic so that the deep operating field can be clearly seen. LN, lymph node.
A detailed surgical procedure video has been attached to the Supplementary Video 1 (only online). After the specimen was extracted, the surgical site was marked with surgical clips for future radiotherapy.
If the mass was palpable, resection was performed without localization needling. In cases where the mass could not be felt, ultrasound-guided localization needling was performed. After removing the mass, margin positivity was confirmed through a frozen test. The surgery was completed after confirming that no cancer remained in the margin. After the specimen was extracted, the surgical site was marked with surgical clips for future radiotherapy.
Ethics
This retrospective study was approved by the Institutional Review Board (IRB) of Yonsei University Severance Hospital (registration number: 4-2020-1440). The requirement for informed consent was waived by the IRB due to the retrospective nature of the study.
RESULTS
The total number of BCS with axillary staging included in the study was 244: 127 in the group using the energy devices and 117 in the group using the conventional method. Tumors were completely removed in each group.
The clinicopathological characteristics are summarized in Table 1. The mean age of the patients was 53.1 years in the SIBCS group and 55.9 years in the CBCS group. There were no significant differences between the two groups except for nodal status and neoadjuvant therapy. Node-positive tumors were more common in the SIBCS group than in the CBCS group. There was a significantly higher rate of neoadjuvant chemotherapy in the SIBCS group than in the CBCS group. In the final pathology result, there were two cases (1.70%) with positive margins in the CBCS group and no such case in the SIBCS group.
Table 1. Clinical Characteristics of the Patients (n=244).
| CBCS (n=117) | SIBCS (n=127) | p value | ||
|---|---|---|---|---|
| Age (yr) | 55.90±10.10 | 53.10±11.00 | 0.065 | |
| BMI (kg/m2) | 23.62±3.03 | 23.35±3.54 | 0.523 | |
| Pathologic type | 0.284 | |||
| IDC | 96 (82.10) | 111 (87.40) | ||
| DCIS | 21 (18.00) | 5 (3.90) | ||
| Other | 14 (12.00) | 11 (8.70) | ||
| Histologic grade | 0.144 | |||
| 1 | 33 (28.20) | 31 (24.40) | ||
| 2 | 43 (36.80) | 63 (49.60) | ||
| 3 | 32 (27.40) | 29 (22.80) | ||
| Unknown | 9 (7.70) | 4 (3.10) | ||
| Pathologic T stage | 0.242 | |||
| ≤T1 | 107 (91.50) | 115 (90.50) | ||
| T1> | 10 (8.50) | 12 (9.40) | ||
| Tumor size (mm) | 12.10±7.80 | 11.00±7.70 | 0.274 | |
| Distance from nipple (cm) | 4.00±3.00 | 4.00±3.00 | 0.840 | |
| Nodal status | 0.022 | |||
| Node negative | 106 (90.60) | 103 (81.10) | ||
| Node positive | 11 (9.40) | 24 (18.10) | ||
| Number of lymph nodes retrieved | 0.931 | |||
| ≤5 | 99 (84.60) | 104 (81.80) | ||
| 5>and<11 | 12 (10.20) | 21 (16.50) | ||
| 11≥ | 6 (5.10) | 2 (1.50) | ||
| ER | 0.479 | |||
| Negative | 32 (27.40) | 40 (31.50) | ||
| Positive | 85 (72.60) | 87 (68.50) | ||
| PR | 0.172 | |||
| Negative | 46 (39.30) | 61 (48.00) | ||
| Positive | 71 (60.70) | 66 (52.00) | ||
| Her2 | 0.648 | |||
| No overexpression | 96 (82.10) | 107 (84.30) | ||
| Overexpression | 21 (17.90) | 20 (15.70) | ||
| Ki-67 | 0.218 | |||
| <14 | 49 (41.90) | 51 (40.20) | ||
| ≥14 | 68 (58.10) | 74 (58.30) | ||
| Unknown | 0 (0) | 2 (1.60) | ||
| Neoadjuvant therapy | 0.009 | |||
| Not done | 105 (89.70) | 98 (77.20) | ||
| Done | 12 (10.30) | 29 (22.80) | ||
| ASA score | 0.999 | |||
| <2 | 95 (81.90) | 104 (81.90) | ||
| ≥2 | 21 (18.10) | 23 (18.10) | ||
ASA, American Society of Anesthesiology; BMI, body mass index; CBCS, conventional breast-conserving surgery; DCIS, ductal carcinoma in situ; ER, estrogen receptor; IDC, invasive ductal carcinoma; PR, progesterone receptor; SIBCS, single-incision breast-conserving surgery.
Data are expressed as n (%) or mean±SD.
Table 2 summarizes the postoperative outcomes in both groups. Incision size was significantly smaller in the group with advanced energy devices than in the group with conventional method (6.3±2.1 cm vs. 7.5±2.5 cm, p=0.044). There were no significant differences between the groups in terms of operating time (126.0±40.0 min vs. 127.0±63.0 min, p=0.828), operative blood loss (11.0±31.0 mL vs. 7.0±18.0 mL, p=0.100), drainage duration (7.0±3.0 d vs. 8.0±4.0 d, p=0.288), and complications (1.70% vs. 2.36%, p=0.523). Most patients were discharged with an axilla drain. The patients directly recorded the amount drained for 2 weeks, and the data was brought to the outpatient clinic. If the amount of drain decreased to less than 20 cc, the drain was removed at an outpatient clinic. Drainage was mostly serous immediately after surgery. The rate of postoperative complication in each group was 1.7% in CBCS and 2.36% in SIBCS. One case in the CBCS group had partial NAC ischemia after surgery, and the course was resolved without any other treatment. In one case of CBCS, surgical site infection developed 1 month after surgery. This patient was hospitalized via the emergency room and discharged after improvement in the course of treatment with antibiotics. In three cases of SIBCS, primary repair was performed under local anesthesia due to wound dehiscence in an outpatient follow-up after surgery.
Table 2. Comparison of Postoperative Outcomes between CBCS and SIBCS (n=244).
| CBCS (n=117) | SIBCS (n=127) | p value | |
|---|---|---|---|
| Incision size (cm) | 7.50±2.50 | 6.30±2.10 | 0.044 |
| Operation time (min) | 127.00±63.00 | 126.00±40.00 | 0.828 |
| Drain volume at POD#0 (mL) | 49.90±29.20 | 54.10±32.80 | 0.293 |
| Duration of drainage (day) | 8.00±4.00 | 7.00±3.00 | 0.288 |
| Blood loss (mL) | 7.00±18.00 | 11.00±31.00 | 0.100 |
| Complications | 2.00 (1.70) | 3.00 (2.36) | 0.523 |
CBCS, conventional breast-conserving surgery; POD, postoperative day; SIBCS, single-incision breast-conserving surgery.
Data are expressed as mean±SD or n (%).
Table 3 shows the comparison of additional incisions according to surgery. In the 244 samples, 12 cases in which additional incision was not recorded in the surgical record were classified as unknown data. In CBCS, there was an additional incision in 60 patients (57%) out of a total of 105 patients. Additionally, in SIBCS, there was an additional incision in only 10 patients (7.9%) out of a total of 127 patients. Therefore, the number of cases requiring additional incision in SIBCS was significantly lower than that in CBCS.
Table 3. Comparison of Additional Incisions According to Surgery.
| CBCS (n=105*) | SIBCS (n=127) | p value | |
|---|---|---|---|
| Additional incision | 60 (57.1) | 10 (7.9) | <0.001 |
| No additional incision | 45 (42.9) | 117 (92.1) |
CBCS, conventional breast-conserving surgery; SIBCS, single-incision breast-conserving surgery.
Data are expressed as n (%).
*Cases where additional incision was not recorded in the surgical record were considered unknown data, which was all in CBCS group (n=12).
Table 4 shows the comparison of additional incision made in the quadrant excluding the upper outer mass. Of the total 244 cases, excluding the case where there was a mass in the upper outer, there were 70 cases in CBCS and 84 cases in SIBCS, respectively. When performing axillary staging, additional axillary incision was required in 78.6% of cases with CBCS. In SIBCS, additional incision was required in only 10.7% of cases, and axillary staging was possible with a peri-areolar single incision in the remaining 89.3% of cases. This means that the number of cases requiring additional incision for axillary staging in SIBCS was significantly lower compared to CBCS.
Table 4. Comparison of SLNB and ALND Cases When There Is an Additional Incision.
| CBCS with additional incision (n=60) | SIBCS with additional incision (n=10) | p value | |
|---|---|---|---|
| SLNB | 58 (96.66) | 8 (80.00) | 0.036 |
| ALND | 2 (3.33) | 2 (20.00) |
CBCS, conventional breast-conserving surgery; SIBCS, single-incision breast-conserving surgery; SLNB, sentinel lymph node biopsy; ALND, axillary lymph node dissection.
Data are expressed as n (%).
Table 5 represents the satisfaction of patients through BREAST-Q. There was no significant difference between CBCS and SIBCS. Breast-Q is attached as Supplementary Material (only online).
Table 5. BREAST-Q Postoperative Scales.
| CBCS (n=14) | SIBCS (n=16) | p value | |
|---|---|---|---|
| Psychosocial well-being | 74.50±18.69 | 68.56±19.62 | 0.404 |
| Satisfaction with breast | 59.71±14.29 | 56.13±10.90 | 0.452 |
| Physical well-being: chest | 40.07±21.11 | 53.25±22.16 | 0.107 |
CBCS, conventional breast-conserving surgery; SIBCS, single-incision breast-conserving surgery.
Data are expressed as mean±SD.
Fig. 3 shows postoperative scars of the SIBCS and CBCS groups. CBCS was performed via skin incision just above the tumor location. Fig. 3A shows additional axillary incision for axillary staging in a patient who underwent CBCS. Fig. 3B shows SLNB performed via a single curved incision in the upper area of the right breast without additional axillary incision. Fig. 3F shows that SIBCS was performed via a single peri-areolar incision without axillary incision. Fig. 3C and D shows peri-areolar incision. Drain was also put in peri-areolar to prevent invisible scar. Fig. 3E and F shows inconspicuous incision 1 year after surgery.
Fig. 3. Pictures of postoperative scar. All incisions are indicated by arrows in the figure. (A) CBCS with radial incision. (B) CBCS with radial incision and extra axillary incision. (C) Peri-areolar SIBCS using energy device during immediate post-operation. (D) (Round block) SIBCS using energy device at 2 weeks after surgery (operated breast is the right side). (E) Peri-areolar SIBCS using energy device at 2 years after surgery (operated breast is the right side). (F) Peri-areolar SIBCS using energy device at 4 years after surgery (operated breast is the left side). The incision is inconspicuous. CBCS, conventional breast-conserving surgery; SIBCS, single-incision breast-conserving surgery.
DISCUSSION
To our best knowledge, this is the first study to devise a method for axillary lymph node dissection as well as SLNB using a peri-areolar single incision with an energy device and fiberoptic retractors. Minimally invasive surgery is a recent concept in breast cancer surgery, and its development has been based on two procedures; endoscopic assistance and a single incision.13 The endoscopic procedures ensure an inconspicuous scar after tumor resection and SLNB. Since axillary dissection is performed at the beginning of surgery, it has the advantage of easier conduction of breast tumor resection and later remodeling. However, for the breast surgeon who is unfamiliar with endoscopy, this may be a difficult surgical method.14 When performing endoscopic surgery, additional expensive devices, such as an endoscope, media equipment that can record it, and a monitor, are required. In contrast, SIBCS can be attempted without much difficulty even by surgeons familiar with the conventional methods. A single peri-areolar incision was made, and it was used to perform axillary staging after tumor resection. The long shaft of the energy devices and the handheld fiberoptic retractors made this process possible without additional incisions. The fiberoptic retractors lift the flap, providing the surgeon with a good view. Therefore, in a situation in which such a field of view is secured, the surgeon can subsequently reach the axilla with ease, using an energy device with a long shaft.
There were no significant differences in the clinicopathological characteristics between the groups except for two variables. There were significantly more patients with node-positive disease in the SIBCS group. This was due to the surgeon’s preference for using energy devices for axillary lymph node dissection after the application of energy devices in axillary surgery. In addition, there were significantly more patients who received neoadjuvant chemotherapy in the SIBCS group, which may be due to selection bias. In our institution, patients with node-positive disease in preoperative diagnosis usually received neoadjuvant therapy. This is related to the finding that there were higher proportions of node-positive disease and neoadjuvant chemotherapy in the SIBCS group. There was no significant difference in tumor size in each group, which is thought to be because neoadjuvant chemotherapy was performed first in the case of advanced breast cancer. This finding might be attributed to easier axillary staging when a skilled surgeon uses an energy device. In studies by Acea-Nebril, et al.,13 single-incision surgery had no significant differences in the surgical outcomes except in operation time. On average, single-incision surgery took 18.6 minutes longer than conventional surgery, but it was difficult to see a significant clinical difference. There was no difference in operating time between the two groups in our study. However, since the surgery was performed by one experienced surgeon, additional research is needed to determine whether there will be a difference in operating time when another surgeon performs the same technique.
The incision size was smaller in SIBCS and provided a clue to improve cosmesis, as there was no additional axillary incision. SIBCS showed a smaller incision size by a mean of 1.2 cm compared to the conventional surgical method. As shown in Fig. 3, when operated with a peri-areolar single incision, scars were scarcely noticeable, and symmetry of both breasts was maintained. Since cosmesis is subjective, it is difficult to measure. Subjective satisfaction can be investigated by tracking patients in an outpatient setting using the BREAST-Q questionnaire. However, in this study, there was no significant difference in the BREAST-Q questionnaire between the two groups due to the small sample size. Since this was a retrospective study, there were limited number of patients available for the questionnaire survey. However, a previous study12 showed greater satisfaction with the breast cosmesis and information provided by the surgeon. Therefore, it seems that the improvement in satisfaction can also be proven through a prospective study on the SIBCS.
There were no significant differences in operation time, amount of bleeding, drainage period, or complications when compared with those of the conventional operation. This proves that SIBCS is safe from a surgical perspective, and can improve cosmesis.
When comparing CBCS and SIBCS, the number of cases requiring additional incisions in SIBCS was significantly smaller. Through this, we can propose a surgical method that allows for sufficient axillary staging with a single incision when using an advanced energy devices and fiberoptic retractor.
In general, axillary staging of the mass on the upper outer side was possible with a single axillary incision in CBCS. Therefore, when checking the cases in which additional incisions were made in the remaining quadrants excluding the upper outer, the number of cases in which additional incisions were made in the SIBCS group was significantly lower compared to CBCS. Therefore, if an energy device and a fiberoptic retractor are used appropriately, it can be suggested that axillary staging is possible with a single incision even if the mass is not in the upper outer quadrant.
Also, there were no significant differences between the two groups in terms of satisfaction of breast after surgery surveyed through BREAST-Q. However, since the questionnaire was conducted on a limited group of 30 patients, it is difficult to consider this result as meaningful. Since this was a retrospective study, it had limitations in examining patient satisfaction on an outpatient basis. Although the sample was small and there was no statistical difference between the two groups, the overall satisfaction of patients was high.
This study had some limitations. First, it was a retrospective study. Additionally, the short follow-up period for the series also prevented us from analyzing the safety of this procedure in the medium term in terms of the overall and disease-free survival. This should be supplemented through prospective studies in the future.
However, this study demonstrated for the first time that BCS via a single peri-areolar incision without additional axillary incision can be performed using advanced energy devices and handheld fiberoptic retractors. This surgical approach results in a hidden postoperative scar. Although it was not statistically significant, intuitively, as shown in Fig. 3, there is a cosmetic advantage in that no scars are visible. Since the BREAST-Q investigated in this study was scored using a limited sample, the results need to be strengthened in prospective studies.
ACKNOWLEDGEMENTS
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2022R1C1C1010441) and a faculty research grant of Yonsei University College of Medicine (6-2021-0239).
Footnotes
Hyung Seok Park has received honoraria from AstraZeneca, Takeda, Ethicon, Medtronic, and Intuitive Surgical. The rest of co-authors have no conflict of interest to disclose.
- Conceptualization: Hyung Seok Park.
- Data curation: Hye Jin Kim, Kwanbum Lee, and Hyung Seok Park.
- Formal analysis: Hye Jin Kim, Kwanbum Lee, and Hyung Seok Park.
- Funding acquisition: Hyung Seok Park.
- Investigation: Hye Jin Kim, Kwanbum Lee, and Hyung Seok Park.
- Methodology: Kwanbum Lee, Jeea Lee, and Hyung Seok Park.
- Project administration: Hyung Seok Park.
- Resources: Hye Jin Kim, Jeea Lee, and Hyung Seok Park.
- Software: Junho Cho and Hyung Seok Park.
- Supervision: Jeea Lee and Hyung Seok Park.
- Validation: all authors.
- Visualization: Hye Jin Kim and Hyung Seok Park.
- Writing—original draft: Hye Jin Kim and Hyung Seok Park.
- Writing—review & editing: Hye Jin Kim, Dong-Min Shin, Junho Cho, and Hyung Seok Park.
- Approval of final manuscript: all authors.
DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article. If the data are needed, contact the corresponding author.
SUPPLEMENTARY DATA
Finding blue dyed LN using an energy device, visibility secured with fiberoptic retractors.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Finding blue dyed LN using an energy device, visibility secured with fiberoptic retractors.
Data Availability Statement
Data sharing is not applicable to this article. If the data are needed, contact the corresponding author.