Modified abdominal advancement flap with the Ochikomanai method: Oncoplastic surgery with a simple volume replacement technique

Modified abdominal advancement flap with the Ochikomanai method: Oncoplastic surgery with a simple volume replacement technique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Modified abdominal advancement flap with the Ochikomanai method: Oncoplastic surgery with a simple volume replacement technique Erina Hatakawa, Rena Kojima, Ayu Yamaguchi, Kaho Nakamura, Rena Yamakado, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4668833/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Breast-conserving surgery (BCS) of the lower portion of the breast results in poor cosmetic outcomes. Therefore, a simple and suitable technique for performing BCS for breast cancer in the lower region is needed. In 2010, we developed an abdominal advancement flap (AAF) as a simple technique. However, BCS with an AAF could have worse cosmetic results when used in older patients and those with larger breasts. Therefore, we developed the even simpler volume replacement technique based on the AAF in 2017, called the “modified AAF.” Methods We conducted a retrospective cohort study focusing on the usefulness of the modified AAF, including cosmetic results and patient satisfaction, in 88 patients (89 breasts) who underwent BCS using the modified AAF with or without the Ochikomanai method. Results Ten patients had complications (11%); however, no fat necrosis was observed, and all complications improved with conservative treatment. With regard to cosmetic results, 41 breasts (58%) were rated excellent, 26 breasts (37%) were rated good, and only 4 were unacceptable, all of which were rated fair. Patients with medium- or larger-sized breasts and older patients who underwent BCS using modified AAF with or without the Ochikomanai method had acceptable cosmetic results. More than 89% of patients indicated they were somewhat or very satisfied in all eight categories, except for physical limitations in the immediate postoperative period. Conclusion BCS using a modified AAF, with or without the Ochikomanai method, is a useful technique for many patients, including patients who are older or have larger breasts. Breast cancer Breast-conserving surgery Oncoplastic surgery Reconstructive surgical procedure Volume replacement technique Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Breast-conserving surgery (BCS) is the standard treatment for early breast cancer with the goal of maintaining good cosmetic results and oncological safety [ 1 ]. However, BCS in the lower portion of the breast results in poor cosmetic outcomes [ 2 ]. To improve the cosmetic results of BCS for breast cancer in the lower portion, breast oncoplastic surgery with the application of a reduction technique, which was originally used in the field of aesthetic plastic surgery, emerged in Europe and the United States in the 1990s [ 3 , 4 ]. There are two types of oncoplastic surgeries. The first is the volume displacement technique, which applies the aforementioned reduction techniques to repair defects using the intramammary tissue. The second is the volume replacement technique, which uses extramammary tissue to repair breast defects after BCS [ 5 ]. Since most Japanese women's breasts are too small to remodel with only a volume displacement technique and because Japanese patients prefer not to operate on the unaffected side, volume replacement techniques are preferred. Some volume replacement methods such as the use of perforator flaps and latissimus dorsi myocutaneous flaps have been reported [ 6 , 7 ]. These flaps could be used to fill large defects. However, these techniques are complex and result in the formation of additional donor site scars, which often preclude their use. To improve the cosmetic results of breast cancer treatment in the lower portion of the breast in Japanese women, we started performing BCS using an abdominal advancement flap (AAF) in 2010. AAF is a simple volume replacement technique that can be performed by breast surgeons. Initially, we considered that BCS with AAF would have better cosmetic results when used in younger patients, those with lower Body Mass Index (BMI) and those with smaller and non-ptotic breasts. However, in our previous study, we found that the percentage of unacceptable cases increased when AAFs were used in patients with a high BMI, large breasts, tumors located in the inner portion, and old age [ 8 ]. Additionally, AAFs are difficult to perform in patients at high risk of impaired blood flow, such as older patients and those with diabetes, because the technique requires extensive skin flap creation. Therefore, there was a need to develop techniques that could be used in patients without indications for AAF. To fill this need, we developed an even simpler volume replacement technique based on the AAF in 2017 and named the technique “modified AAF.” Modified AAF is a technique for filling a defect using the skin and subcutaneous tissue of the upper abdomen and lateral chest and reconstructing the inframammary fold (IMF) simultaneously. Because of the simplicity of the procedure, we expanded the indications for modified AAF. However, if the skin on the tumor was not removed during the filling process, the excess skin over the defect would sink in and wrinkle. Even if the breast shape was good and the excess skin was sunken, the evaluation of cosmetic results was likely to decrease, and if the cosmetic results were poor, both the patients and breast surgeons would feel down. Therefore, we developed a simple solution to solve the problem of excess skin depression, named the “Ochikomanai method.” “Ochikomanai” means both “not sinking” and “not feeling down” in Japanese. Therefore, in patients with extra skin over the defect, we have used modified AAF with the “Ochikomanai method.” Herein, we report the use of modified AAF with and without the Ochikomanai method for BCS and assess their usefulness based on cosmetic results and patient satisfaction. Patients and methods We conducted a retrospective cohort study focusing on the usefulness, including cosmetic results and patient satisfaction, of BCS using modified AAF with or without the Ochikomanai method. This study was approved by the Ethics Committee of Mie University (registration no: H2022-176). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. This study included 88 patients (89 breasts) with primary breast cancer or benign breast tumors who underwent BCS or lumpectomy using modified AAF at the Mie University Hospital between June 2017 and April 2022. The surgeries were performed by breast surgeons without the help of plastic surgeons. The indication for BCS or tumorectomy with modified AAF was when the lesion was not located in the upper-inner quadrant. We performed modified AAF when the amount of tissue from the IMF to the new IMF (neo-IMF) was considered to be at least 80% of the resection volume. The Ochikomanai method was used when there was excess skin after modified AAF. Surgical techniques The procedure for creating a modified AAF is as follows (Fig. 1 ). Before the operation, the original IMF, neo-IMF, height of the nipple on the unaffected side, and skin incision line were marked with the patient in the standing position. The neo-IMF was marked where the skin could be easily lifted to the height of the original IMF, and the position of the neo-IMF was approximately 3–5 cm below the IMF. The skin incision line was parallel to the neo-IMF. Next, we performed BCS. After BCS, the mammary gland on the chest wall on the caudal side was undermined until the neo-IMF was reached. Similarly, the mammary gland on the chest wall on the cranial side was undermined extensively. A slit was made close to the skin in the subcutaneous tissue of the neo-IMF. Some absorbable sutures were inserted into the subcutaneous tissue of the neo-IMF in 1 cm width. We also verified that the neo-IMF was smooth by applying traction to the sutures. By The slit of the neo-IMF, a sharp angle was formed. The sutures were then tied and fixed to the cranial mammary tissue. Creating the neo-IMF using this procedure allows the filling of a defect from partial resection and pulls the nipple-areola complex down to the same height as that on the unaffected side. If there was excess skin due to a small amount of skin resection on the tumor, we additionally performed the “Ochikomanai method” (Fig. 2 ). In the Ochikomanai method, de-epithelized excess skin props up the skin over the defect and fills it at the time of skin closure. The skin on the cranial side of the wound covered the skin on the caudal side of the wound, and the skin on the caudal side of the overlapping area was de-epithelized. The de-epithelized skin and upper mammary glands were sutured and fixed. Assessment of reconstruction To assess reconstruction, we performed a cosmetic evaluation by seven breast surgeons and a patient satisfaction evaluation. Cosmetic evaluation was performed using photographs taken more than 6 months after the operation. We evaluated the cosmetic results of 71 patients who did not require reoperation and were photographed more than 6 months after the operation. Photographs of the patients’ breasts were taken in frontal, left oblique, and right oblique views without any identifying features. The cosmetic results were then evaluated by seven independent observers (breast surgeons) as “excellent,” “good,” “fair,” or “poor” using the Harvard Scale established by Harris et al [ 9 ]. An excellent result indicated that the treated breast was nearly identical to the untreated breast; a good result indicated that the treated breast was slightly different from the untreated breast; a fair result indicated that there was an obvious difference between the two sides without major distortion; and a poor result indicated that the treated breast was seriously distorted. We classified excellent and good results as acceptable and fair and poor results as unacceptable. The observers were blinded to the identities of all patients. Patient evaluation was conducted using a questionnaire. We provided questionnaires to 68 patients who were undergoing postoperative follow-up at the Mie University Hospital, had not undergone residual mastectomy, and were able to complete the questionnaire in Japanese. The questionnaire was sent to the target patients after confirming at the outpatient clinic that it was acceptable to send the questionnaire. The questionnaire included nine items: early postoperative physical limitations, current physical limitations, breast shape when dressing, breast shape when undressing, breast size, surgical scarring, whether they would recommend this surgery to others in the same situation, psychological resistance to public bathing, and comparison with preoperative expectations. For each item, patients rated their satisfaction on a 4-point scale. Results Patient characteristics are shown in Table 1 . Eighteen patients (20%) were over 65 years old, and 22 patients (25%) had a BMI of over 25 kg/m 2 . Extra small, small, and medium breast sizes accounted for 89% (76) of the breasts. Breast ptosis was evaluated using the Regnault classification, and 17 patients (20%) had ptotic breasts. Regarding the mammary gland density, 67 (75%) dense breasts were observed. Six patients with diabetes and nine smokers were included in this study. Table 1 Clinical characteristic of patients Age (years) n = 88 Average (range) 54.3 (28–81) ≥65 years 18 Body mass index, kg/m 2 n = 88 Average (range) 22.9 (15.8–31.5) ≥25 kg/m 2 22 Breast size n = 85* Extra small 9 Small 32 Medium 35 Large 5 Extra large 3 Breast ptosis n = 85* None 68 Grade Ⅰ 6 Grade Ⅱ 9 Grade Ⅲ 2 Breast density n = 89 Dense breast 67 Scattered breast 22 Patients with diabetes mellitus 6 Smokers 9 * Breast size and ptosis were classified based on perioperative breast photographs. Therefore, only 85 breasts photographed perioperatively were included in this classification. The surgical data are presented in Table 2 . The excision volume, compared to the total breast volume, was estimated using a preoperative photograph of the markings made for the partial resection area by seven independent observers (breast surgeons). The average excision volume relative to breast volume was 16.6%. The excision volume percentage of the total breast volume was > 25% in nine breasts (11%). The tumor was located in the outer upper or lower quadrants in 72 patients (81%). Operative time and blood loss were examined in 68 patients, excluding patients in whom surgery was performed on both sides of the breast, axillary dissection was performed, SNB was not performed, or intraoperative complications (hook wire straying) occurred. The average operative time was 1 h and 45 min, and the average blood loss was 14.7 g. Table 2 Surgical data Proportion of excision volume (%) * n = 83 5% 2 10% 17 15% 29 20% 26 25% 6 30% 3 Location of the tumor n = 89 Central 7 Inner upper 5 Inner lower 5 Outer upper 42 Outer lower 30 Axillary treatment n = 89 None (breast surgery only) 11 Sentinel lymph node biopsy only 69 Blood loss** n = 68 Range (g) 0–46 Average (g) 14.7 Operation time** n = 68 Range (minutes) 61–164 Average (minutes) 103 Axillary dissection (including sampling) 9 Combining technique n = 89 Only mobilization (including the Ochikomanai method) 86 Round block technique 1 Modified round block technique 2 Nipple-areola complex excision 2 Additional surgery n = 89 No 77 Yes (mastectomy) 8 Yes (re-excision) 4 Postoperative complication *** n = 81 Total 10 Treatment for complications Reoperation due to complications 0 Only conservative treatment 10 Complication details Wound infection 4 Postoperative bleeding 3 Delayed wound healing 6 Wound dehiscence 3 Nipple-areola complex/skin necrosis 3 Intertrigo around the neo-IMF 1 Fat necrosis 0 * Six breasts without preoperative photographs were excluded. ** One patient with intraoperative trouble (hook-wire straying) was excluded. *** Eight patients who underwent mastectomy after BCS were excluded. Neo-IMF: new inframammary fold; BCS: breast-conserving surgery To reshape the breast, modified AAF combined with mobilization of the glandular flap (with or without the Ochikomanai method) was performed in 86 breasts (97%), and round-block techniques were performed concurrently in 3 breasts (2 patients). The nipple-areola complex was resected in two patients. Due to positive or near margins, 8 breasts underwent mastectomy and 4 breasts underwent re-excision. Ten patients (11%) developed complications of modified AAF; however, no fat necrosis was observed, and all complications improved with conservative treatment. With regard to the cosmetic results, there were no cases of poor ratings, and 94% of patients had acceptable outcomes (excellent or good ratings). There were 46 breasts (65%) rated excellent, 21 breasts (30%) rated good, and only 4 unacceptable breasts, all of which were fair (Fig. 3 ). The patient evaluation results are shown in Fig. 4 . We sent patient evaluation questionnaires to 68 patients, 53 of whom responded, and 45 provided permission for their questionnaires to be used in this study. More than 40 patient (89%) of the 45 answered that they were somewhat or very satisfied in all eight categories, with the exception of physical limitations in the immediate postoperative period. In particular, all patients indicated they were somewhat or very satisfied with regard to current physical limitations, breast shape when dressing, and comparison with preoperative expectations. More than 42 patients (93%) rated their satisfaction as either satisfied or generally satisfied with the five items directly assessing cosmetic results. Discussion BCS in the lower portion of the breast results in poor cosmetic outcomes. However, most of the currently known breast oncoplastic surgical techniques for lower-portion breast cancer are suitable only for larger breasts or require complex procedures. The breasts of Japanese women are not as large as those of western women, and complex procedures are not suitable for all cases. Therefore, there is a need to develop a simple technique suitable for lower-portion breast cancers in small- and medium-sized breasts, which are common in the Japanese population. In 2010, we initiated BCS using AAF for breast cancer in the lower portion of the breast. However, in our previous study [ 8 ], 26.8% of patients who underwent BCS with AAF had unacceptable cosmetic results. In particular, the percentage of unacceptable cases increased when the AAF was used in patients with medium-sized breasts. In addition, unacceptable outcomes were observed more frequently in older patients. Therefore, we developed a modified AAF with or without the Ochikomanai method based on the AAF for breast cancer in the lower portion of the breast. We also compare the cosmetic utility of standard and modified AAF in Table 3 . Table 3 Comparison with AAF AAF[ 8 ] (n = 31) modified AAF (n = 71*) Age (average, years) 53.3 54.3 BMI (average, kg/m 2 ) 22.2 22.9 Breast size Extra small 10 (24%) 7 (10%) Small 22 (54%) 27 (38%) Medium 9 (22%) 31 (44%) Large 0 5 (7%) Extra large 0 2 (3%) Excision volume (average) 21% 16.60% Cosmetic result Acceptable 30 (73%) 67 (94%) Age (average, years) 51.8 53.7 Unacceptable 11 (27%) 4 (6%) Age (average, years) 57.2 54.2 Medium/Large/Extra large breast 4 (57%) 2 (5%) *Only patients for whom a postoperative cosmetic assessment was possible were considered for comparison. AAF: abdominal advancement flap; BMI: Body mass index BCS with modified AAF was associated with a higher percentage of acceptable cases than BCS with AAF [ 8 ]. In particular, among patients with medium-sized or larger breasts, 57% who underwent BCS with AAF had unacceptable outcomes, compared to only 5% of those who underwent BCS with modified AAF. Among the patients who underwent BCS with AAF, the average age of those considered to have unacceptable outcomes was higher than that of those with acceptable outcomes, although there were no significant differences. In contrast, among patients who underwent BCS with modified AAF, there were no age differences between those with acceptable and unacceptable outcomes. There are five potential reasons why BCS using modified AAF with or without the Ochikomanai method may result in acceptable outcomes in patients with medium- or larger-sized breasts and in older patients. The first is the small area of subcutaneous dissection. Natural tension in the lower part of the breast is maintained because no subcutaneous dissection is performed for breast reshaping. The second is suture fixation of the neo-IMF and upper mammary gland. This suture fixation allows simultaneous elevation of the neo-IMF and descent of the cranial mammary gland, including the nipple-areola complex. We believe that when the nipple-areola complex descends with the cranial breast tissue, the risk of nipple-areola complex cranial deviation is reduced. The third is the Ochikomanai method. Older patients are more likely to have thin skin and fatty breasts. When a patient with thin skin or fatty breasts undergoes BCS, the excess skin over the defect area of the partial resection is likely to become depressed into the defect. The Ochikomanai method solves the problem of excessive skin depression. The fourth is the excision volume. When BCS was performed with modified AAF, the average percentage of excision volume compared to the total breast volume was lower than that when BCS was performed with AAF. We consider the reason for the reduced resection volume to be the expanded indications for BCS with modified AAF. Although not in comparison with AAF, modified AAF is a simpler procedure, requiring less time for surgery, with only minor complications that can be improved with conservative treatment. The modified AAF is less stressful for both patients and surgeons because the procedure is simpler. Therefore, the indications for BCS with modified AAF were expanded to include not only cases with large resection volumes, which are prone to deformity, but also those with small resection volumes. The final potential reason is improvement of surgeons’ skills. We compared the results of BCS with AAF and modified AAF performed at the same hospital. Both the AAF and modified AAF techniques include IMF reshaping by inserting absorbable sutures into the neo-IMF and elevating it. It is possible that surgeons have become more accustomed to the technique and improved their skills, which may have improved the cosmetic results of BCS using modified AAF. The patient evaluation indicated that patient satisfaction was high in all categories except for postoperative physical limitations. One-third of the patients experienced early postoperative strong physical limitations but generally did not encounter them more than 6 months after surgery. Immediately after the operation, the absorbable sutures can entangle the IMF, and patients often complain of skin tightness. We believe that it is important to explain before surgery that skin tightness may be felt immediately after surgery and then loosen as the absorbable sutures are absorbed. Our study had several limitations. This single-center study in Japan may have limited generalizability. There was a selection bias in that fewer patients with modified AAF had tumors in the inner portion of the breast. The modified AAF technique uses the skin and subcutaneous tissue of the upper abdomen and lateral chest as flaps, and advancing the lateral thoracic tissue into the outer portion is easy. Therefore, we selected cases with good indications for tumors in the outer portion. We do not know whether more patients with tumors in the inner portion of the lesions would necessarily have the same results as those in this study. As this was a retrospective study, the criteria for selecting cases of BCS with modified AAF were not clearly defined, which may have caused selection bias. The use of the BREAST-Q to conduct patient evaluations is becoming increasingly common. However, because the BREAST-Q has a large number of questions, it could reduce the response rate of the patients. Therefore, we developed our original questionnaire using simple questions to increase patient response rates, and all patients who underwent BCS with modified AAF were evaluated using our original questionnaire, which may make it difficult to generalize the assessment. Conclusions In this study, BCS using the modified AAF with or without the Ochikomanai method was simpler and, therefore, less stressful for both patients and surgeons in terms of operating time, blood loss, and complications than AAF. Both cosmetic results and patient satisfaction were satisfactory. We believe that BCS using modified AAF, with or without the Ochikomanai method, is a useful technique. Declarations Compliance with ethical standards Disclosure of potential conflicts of interest None. Research involving Human Participants and/or Animals This study was approved by the Ethics Committee of Mie University and was conducted in accordance with the ethical principles of the Declaration of Helsinki. Informed consent Informed consent was obtained from all individual participants included in the study. References Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. 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Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys. 1979;5:257–61. https://doi.org/10.1016/0360-3016(79)90729-6 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Hospital: Mie Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Mai","middleName":"","lastName":"Shibusawa","suffix":""},{"id":339995717,"identity":"4e65f4eb-f87a-4ae5-a797-aeef5fa84b40","order_by":8,"name":"Mao Kimoto","email":"","orcid":"","institution":"Mie University Hospital: Mie Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Mao","middleName":"","lastName":"Kimoto","suffix":""},{"id":339995718,"identity":"bf81d3cc-b6b2-4607-9843-65ea3f519657","order_by":9,"name":"Nao Imai","email":"","orcid":"","institution":"Mie University Hospital: Mie Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Nao","middleName":"","lastName":"Imai","suffix":""},{"id":339995719,"identity":"ea7eefa6-99f3-4f0e-8588-8802618a9463","order_by":10,"name":"Makoto Ishitobi","email":"","orcid":"","institution":"Mie University Graduate School of Medicine Faculty of Medicine: Mie Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Makoto","middleName":"","lastName":"Ishitobi","suffix":""},{"id":339995720,"identity":"eb21455b-c4c8-45cd-ab5c-b6581c287cef","order_by":11,"name":"Kousuke Kawaguchi","email":"","orcid":"","institution":"Mie University Hospital: Mie Daigaku Igakubu Fuzoku Byoin","correspondingAuthor":false,"prefix":"","firstName":"Kousuke","middleName":"","lastName":"Kawaguchi","suffix":""},{"id":339995721,"identity":"2ea2402e-a6b8-4dd5-b385-0a8d71a36146","order_by":12,"name":"Tomoko Ogawa","email":"","orcid":"https://orcid.org/0000-0002-1769-8260","institution":"Mie University Graduate School of Medicine Faculty of Medicine: Mie Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Tomoko","middleName":"","lastName":"Ogawa","suffix":""}],"badges":[],"createdAt":"2024-07-01 14:42:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4668833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4668833/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66375113,"identity":"5a409de8-aa26-4dba-9d26-d0a6d5e10274","added_by":"auto","created_at":"2024-10-11 05:38:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":256165,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic illustrations of the surgical procedure of the modified AAF.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFig. 1-a Preoperative markings and postoperative condition. (a) Preoperative markings. The neo-IMF was marked such that it could be easily lifted to the height of the original IMF. The skin incision line was set parallel to the neo-IMF. The area between the IMF and neo-IMF was the upper abdominal and lateral thoracic tissue used for defect filling, as shown in pink. (b) Postoperative conditions. The range from the IMF to the neo-IMF was included in the breast and is shown in pink.\u003c/p\u003e\n\u003cp\u003eb Vertical views of the procedures. (a) BCS was performed. (b) Extensive undermining of the mammary gland on the chest wall on the caudal side to the neo-IMF and on the cranial side. (c) By cutting the subcutaneous tissue of the neo-IMF, it became a sharp angle. (d) Absorbable interrupted sutures were inserted into the subcutaneous tissue of the neo-IMF in 1 cm width. \u0026nbsp;(e) The sutures were threaded through the cranial mammary stamp. (f) The sutures were subsequently tied and fixed to the cranial mammary stamp. The neo-IMF was created by filling a defect in the partial resection and pulling the NAC down to the same height as the unaffected side. AAF: abdominal advancement flap; neo-IMF: new inframammary fold; IMF: inframammary fold; NAC: Nipple-areola complex\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4668833/v1/66478d429d29eed87d551254.png"},{"id":66374783,"identity":"cb5ae913-a1ff-4ee3-8a05-25b5861d42d5","added_by":"auto","created_at":"2024-10-11 05:30:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":363378,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic illustrations of the surgical procedure and operation photos of the Ochikomanai method.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFig. 2-a Schematic illustrations of the Ochikomanai method surgical procedure. (a) The skin on the cranial side of the wound covered the skin on the caudal side of the wound; the skin on the caudal side of the overlapping area was marked. (b) The skin on the caudal side of the overlapping area was de-epithelized. (c) De-epithelized skin and upper mammary glands were sutured and fixed. Fig. 2-b Operation photos of the Ochikomanai method. (a) The skin on the caudal side of overlapping area was marked. (b, c) The skin on the caudal side of the overlapping area was de-epithelized. (d) De-epithelized skin and upper mammary glands were sutured and fixed\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4668833/v1/08e124ac74dd9353ba2ad1e3.png"},{"id":66374779,"identity":"d8da9e8e-f721-4ec5-9827-4b1f25476cb4","added_by":"auto","created_at":"2024-10-11 05:30:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":372485,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCosmetic results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFig. 3-a Overall cosmetic results. We included only patients who did not require reoperation and were photographed more than 6 months after the operation. Fig. 3-b. A representative case of excellent results. The patient was 33 years old with a BMI of 27.3 kg/m\u003csup\u003e2\u003c/sup\u003e. Her breast was medium-sized. The excisional volume was 15%. (a) Preoperative markings. (b) Photographs taken 1 year and 4 months postoperatively.\u003c/p\u003e\n\u003cp\u003eFig. 3-c A representative case of good results. The patient was 61 years old with a BMI of 24.7 kg/m\u003csup\u003e2\u003c/sup\u003e. Her breast was small-sized. The excisional volume was 15%. (a) Preoperative markings. (b) Photographs taken 1 year after the operation. Fig. 3-d A representative case of good rating at cosmetic result. The patient was 53 years old with a BMI of 21.1 kg/m\u003csup\u003e2\u003c/sup\u003e. Her breast was medium-sized. The excisional volume was 15%. (a) Preoperative markings. (b) Photographs taken 1 year and 2 months postoperatively. The reason for the fair evaluation was the mild deviation of the nipple-areola complex. BMI: Body mass index\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4668833/v1/1e0cb3494445d703b2f46d33.png"},{"id":66374781,"identity":"583ac18b-f4c0-4ae0-9d66-387f19ec3459","added_by":"auto","created_at":"2024-10-11 05:30:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42250,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePatient evaluation results\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4668833/v1/7d4e732f293a15398c0019e7.png"},{"id":66376012,"identity":"abae7025-2af9-4e33-8f6a-d681a8ea50a2","added_by":"auto","created_at":"2024-10-11 05:54:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1839715,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4668833/v1/958659fd-010c-4e7d-af2e-c813d2608cb1.pdf"}],"financialInterests":"","formattedTitle":"Modified abdominal advancement flap with the Ochikomanai method: Oncoplastic surgery with a simple volume replacement technique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast-conserving surgery (BCS) is the standard treatment for early breast cancer with the goal of maintaining good cosmetic results and oncological safety [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, BCS in the lower portion of the breast results in poor cosmetic outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. To improve the cosmetic results of BCS for breast cancer in the lower portion, breast oncoplastic surgery with the application of a reduction technique, which was originally used in the field of aesthetic plastic surgery, emerged in Europe and the United States in the 1990s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are two types of oncoplastic surgeries. The first is the volume displacement technique, which applies the aforementioned reduction techniques to repair defects using the intramammary tissue. The second is the volume replacement technique, which uses extramammary tissue to repair breast defects after BCS [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since most Japanese women's breasts are too small to remodel with only a volume displacement technique and because Japanese patients prefer not to operate on the unaffected side, volume replacement techniques are preferred. Some volume replacement methods such as the use of perforator flaps and latissimus dorsi myocutaneous flaps have been reported [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These flaps could be used to fill large defects. However, these techniques are complex and result in the formation of additional donor site scars, which often preclude their use. To improve the cosmetic results of breast cancer treatment in the lower portion of the breast in Japanese women, we started performing BCS using an abdominal advancement flap (AAF) in 2010. AAF is a simple volume replacement technique that can be performed by breast surgeons.\u003c/p\u003e \u003cp\u003eInitially, we considered that BCS with AAF would have better cosmetic results when used in younger patients, those with lower Body Mass Index (BMI) and those with smaller and non-ptotic breasts. However, in our previous study, we found that the percentage of unacceptable cases increased when AAFs were used in patients with a high BMI, large breasts, tumors located in the inner portion, and old age [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, AAFs are difficult to perform in patients at high risk of impaired blood flow, such as older patients and those with diabetes, because the technique requires extensive skin flap creation. Therefore, there was a need to develop techniques that could be used in patients without indications for AAF.\u003c/p\u003e \u003cp\u003eTo fill this need, we developed an even simpler volume replacement technique based on the AAF in 2017 and named the technique \u0026ldquo;modified AAF.\u0026rdquo; Modified AAF is a technique for filling a defect using the skin and subcutaneous tissue of the upper abdomen and lateral chest and reconstructing the inframammary fold (IMF) simultaneously. Because of the simplicity of the procedure, we expanded the indications for modified AAF. However, if the skin on the tumor was not removed during the filling process, the excess skin over the defect would sink in and wrinkle. Even if the breast shape was good and the excess skin was sunken, the evaluation of cosmetic results was likely to decrease, and if the cosmetic results were poor, both the patients and breast surgeons would feel down. Therefore, we developed a simple solution to solve the problem of excess skin depression, named the \u0026ldquo;Ochikomanai method.\u0026rdquo; \u0026ldquo;Ochikomanai\u0026rdquo; means both \u0026ldquo;not sinking\u0026rdquo; and \u0026ldquo;not feeling down\u0026rdquo; in Japanese. Therefore, in patients with extra skin over the defect, we have used modified AAF with the \u0026ldquo;Ochikomanai method.\u0026rdquo; Herein, we report the use of modified AAF with and without the Ochikomanai method for BCS and assess their usefulness based on cosmetic results and patient satisfaction.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eWe conducted a retrospective cohort study focusing on the usefulness, including cosmetic results and patient satisfaction, of BCS using modified AAF with or without the Ochikomanai method. This study was approved by the Ethics Committee of Mie University (registration no: H2022-176). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eThis study included 88 patients (89 breasts) with primary breast cancer or benign breast tumors who underwent BCS or lumpectomy using modified AAF at the Mie University Hospital between June 2017 and April 2022. The surgeries were performed by breast surgeons without the help of plastic surgeons.\u003c/p\u003e \u003cp\u003eThe indication for BCS or tumorectomy with modified AAF was when the lesion was not located in the upper-inner quadrant. We performed modified AAF when the amount of tissue from the IMF to the new IMF (neo-IMF) was considered to be at least 80% of the resection volume. The Ochikomanai method was used when there was excess skin after modified AAF.\u003c/p\u003e \u003cp\u003eSurgical techniques\u003c/p\u003e \u003cp\u003eThe procedure for creating a modified AAF is as follows (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Before the operation, the original IMF, neo-IMF, height of the nipple on the unaffected side, and skin incision line were marked with the patient in the standing position. The neo-IMF was marked where the skin could be easily lifted to the height of the original IMF, and the position of the neo-IMF was approximately 3\u0026ndash;5 cm below the IMF. The skin incision line was parallel to the neo-IMF.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNext, we performed BCS. After BCS, the mammary gland on the chest wall on the caudal side was undermined until the neo-IMF was reached. Similarly, the mammary gland on the chest wall on the cranial side was undermined extensively. A slit was made close to the skin in the subcutaneous tissue of the neo-IMF. Some absorbable sutures were inserted into the subcutaneous tissue of the neo-IMF in 1 cm width. We also verified that the neo-IMF was smooth by applying traction to the sutures. By The slit of the neo-IMF, a sharp angle was formed. The sutures were then tied and fixed to the cranial mammary tissue. Creating the neo-IMF using this procedure allows the filling of a defect from partial resection and pulls the nipple-areola complex down to the same height as that on the unaffected side.\u003c/p\u003e \u003cp\u003eIf there was excess skin due to a small amount of skin resection on the tumor, we additionally performed the \u0026ldquo;Ochikomanai method\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the Ochikomanai method, de-epithelized excess skin props up the skin over the defect and fills it at the time of skin closure. The skin on the cranial side of the wound covered the skin on the caudal side of the wound, and the skin on the caudal side of the overlapping area was de-epithelized. The de-epithelized skin and upper mammary glands were sutured and fixed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAssessment of reconstruction\u003c/p\u003e \u003cp\u003eTo assess reconstruction, we performed a cosmetic evaluation by seven breast surgeons and a patient satisfaction evaluation.\u003c/p\u003e \u003cp\u003eCosmetic evaluation was performed using photographs taken more than 6 months after the operation. We evaluated the cosmetic results of 71 patients who did not require reoperation and were photographed more than 6 months after the operation. Photographs of the patients\u0026rsquo; breasts were taken in frontal, left oblique, and right oblique views without any identifying features. The cosmetic results were then evaluated by seven independent observers (breast surgeons) as \u0026ldquo;excellent,\u0026rdquo; \u0026ldquo;good,\u0026rdquo; \u0026ldquo;fair,\u0026rdquo; or \u0026ldquo;poor\u0026rdquo; using the Harvard Scale established by Harris et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. An excellent result indicated that the treated breast was nearly identical to the untreated breast; a good result indicated that the treated breast was slightly different from the untreated breast; a fair result indicated that there was an obvious difference between the two sides without major distortion; and a poor result indicated that the treated breast was seriously distorted. We classified excellent and good results as acceptable and fair and poor results as unacceptable. The observers were blinded to the identities of all patients.\u003c/p\u003e \u003cp\u003ePatient evaluation was conducted using a questionnaire. We provided questionnaires to 68 patients who were undergoing postoperative follow-up at the Mie University Hospital, had not undergone residual mastectomy, and were able to complete the questionnaire in Japanese. The questionnaire was sent to the target patients after confirming at the outpatient clinic that it was acceptable to send the questionnaire. The questionnaire included nine items: early postoperative physical limitations, current physical limitations, breast shape when dressing, breast shape when undressing, breast size, surgical scarring, whether they would recommend this surgery to others in the same situation, psychological resistance to public bathing, and comparison with preoperative expectations. For each item, patients rated their satisfaction on a 4-point scale.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Eighteen patients (20%) were over 65 years old, and 22 patients (25%) had a BMI of over 25 kg/m\u003csup\u003e2\u003c/sup\u003e. Extra small, small, and medium breast sizes accounted for 89% (76) of the breasts. Breast ptosis was evaluated using the Regnault classification, and 17 patients (20%) had ptotic breasts. Regarding the mammary gland density, 67 (75%) dense breasts were observed. Six patients with diabetes and nine smokers were included in this study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical characteristic of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;88\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.3 (28\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;65 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.9 (15.8\u0026ndash;31.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;25 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;85*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtra small\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtra large\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast ptosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;85*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Ⅰ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Ⅱ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade Ⅲ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDense breast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScattered breast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmokers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* Breast size and ptosis were classified based on perioperative breast photographs. Therefore, only 85 breasts photographed perioperatively were included in this classification.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe surgical data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The excision volume, compared to the total breast volume, was estimated using a preoperative photograph of the markings made for the partial resection area by seven independent observers (breast surgeons). The average excision volume relative to breast volume was 16.6%. The excision volume percentage of the total breast volume was \u0026gt;\u0026thinsp;25% in nine breasts (11%). The tumor was located in the outer upper or lower quadrants in 72 patients (81%). Operative time and blood loss were examined in 68 patients, excluding patients in whom surgery was performed on both sides of the breast, axillary dissection was performed, SNB was not performed, or intraoperative complications (hook wire straying) occurred. The average operative time was 1 h and 45 min, and the average blood loss was 14.7 g.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eProportion of excision volume (%) *\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;83\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLocation of the tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCentral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInner upper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInner lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOuter upper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOuter lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAxillary treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone (breast surgery only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSentinel lymph node biopsy only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlood loss**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperation time**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61\u0026ndash;164\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAxillary dissection (including sampling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCombining technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly mobilization (including the Ochikomanai method)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRound block technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModified round block technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNipple-areola complex excision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAdditional surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (mastectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes (re-excision)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePostoperative complication ***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment for complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReoperation due to complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnly conservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComplication details\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelayed wound healing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNipple-areola complex/skin necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntertrigo around the neo-IMF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFat necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Six breasts without preoperative photographs were excluded.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e** One patient with intraoperative trouble (hook-wire straying) was excluded.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*** Eight patients who underwent mastectomy after BCS were excluded.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNeo-IMF: new inframammary fold; BCS: breast-conserving surgery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo reshape the breast, modified AAF combined with mobilization of the glandular flap (with or without the Ochikomanai method) was performed in 86 breasts (97%), and round-block techniques were performed concurrently in 3 breasts (2 patients). The nipple-areola complex was resected in two patients. Due to positive or near margins, 8 breasts underwent mastectomy and 4 breasts underwent re-excision. Ten patients (11%) developed complications of modified AAF; however, no fat necrosis was observed, and all complications improved with conservative treatment.\u003c/p\u003e \u003cp\u003eWith regard to the cosmetic results, there were no cases of poor ratings, and 94% of patients had acceptable outcomes (excellent or good ratings). There were 46 breasts (65%) rated excellent, 21 breasts (30%) rated good, and only 4 unacceptable breasts, all of which were fair (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient evaluation results are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e4\u003c/span\u003e. We sent patient evaluation questionnaires to 68 patients, 53 of whom responded, and 45 provided permission for their questionnaires to be used in this study. More than 40 patient (89%) of the 45 answered that they were somewhat or very satisfied in all eight categories, with the exception of physical limitations in the immediate postoperative period. In particular, all patients indicated they were somewhat or very satisfied with regard to current physical limitations, breast shape when dressing, and comparison with preoperative expectations. More than 42 patients (93%) rated their satisfaction as either satisfied or generally satisfied with the five items directly assessing cosmetic results.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBCS in the lower portion of the breast results in poor cosmetic outcomes. However, most of the currently known breast oncoplastic surgical techniques for lower-portion breast cancer are suitable only for larger breasts or require complex procedures. The breasts of Japanese women are not as large as those of western women, and complex procedures are not suitable for all cases. Therefore, there is a need to develop a simple technique suitable for lower-portion breast cancers in small- and medium-sized breasts, which are common in the Japanese population. In 2010, we initiated BCS using AAF for breast cancer in the lower portion of the breast. However, in our previous study [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], 26.8% of patients who underwent BCS with AAF had unacceptable cosmetic results. In particular, the percentage of unacceptable cases increased when the AAF was used in patients with medium-sized breasts. In addition, unacceptable outcomes were observed more frequently in older patients. Therefore, we developed a modified AAF with or without the Ochikomanai method based on the AAF for breast cancer in the lower portion of the breast. We also compare the cosmetic utility of standard and modified AAF in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison with AAF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAF[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emodified AAF (n\u0026thinsp;=\u0026thinsp;71*)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (average, years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (average, kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtra small\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtra large\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcision volume (average)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.60%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCosmetic result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (94%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (average, years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (average, years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium/Large/Extra large breast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Only patients for whom a postoperative cosmetic assessment was possible were considered for comparison.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAAF: abdominal advancement flap; BMI: Body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eBCS with modified AAF was associated with a higher percentage of acceptable cases than BCS with AAF [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In particular, among patients with medium-sized or larger breasts, 57% who underwent BCS with AAF had unacceptable outcomes, compared to only 5% of those who underwent BCS with modified AAF. Among the patients who underwent BCS with AAF, the average age of those considered to have unacceptable outcomes was higher than that of those with acceptable outcomes, although there were no significant differences. In contrast, among patients who underwent BCS with modified AAF, there were no age differences between those with acceptable and unacceptable outcomes.\u003c/p\u003e \u003cp\u003eThere are five potential reasons why BCS using modified AAF with or without the Ochikomanai method may result in acceptable outcomes in patients with medium- or larger-sized breasts and in older patients. The first is the small area of subcutaneous dissection. Natural tension in the lower part of the breast is maintained because no subcutaneous dissection is performed for breast reshaping. The second is suture fixation of the neo-IMF and upper mammary gland. This suture fixation allows simultaneous elevation of the neo-IMF and descent of the cranial mammary gland, including the nipple-areola complex. We believe that when the nipple-areola complex descends with the cranial breast tissue, the risk of nipple-areola complex cranial deviation is reduced. The third is the Ochikomanai method. Older patients are more likely to have thin skin and fatty breasts. When a patient with thin skin or fatty breasts undergoes BCS, the excess skin over the defect area of the partial resection is likely to become depressed into the defect. The Ochikomanai method solves the problem of excessive skin depression. The fourth is the excision volume. When BCS was performed with modified AAF, the average percentage of excision volume compared to the total breast volume was lower than that when BCS was performed with AAF. We consider the reason for the reduced resection volume to be the expanded indications for BCS with modified AAF. Although not in comparison with AAF, modified AAF is a simpler procedure, requiring less time for surgery, with only minor complications that can be improved with conservative treatment. The modified AAF is less stressful for both patients and surgeons because the procedure is simpler. Therefore, the indications for BCS with modified AAF were expanded to include not only cases with large resection volumes, which are prone to deformity, but also those with small resection volumes. The final potential reason is improvement of surgeons\u0026rsquo; skills. We compared the results of BCS with AAF and modified AAF performed at the same hospital. Both the AAF and modified AAF techniques include IMF reshaping by inserting absorbable sutures into the neo-IMF and elevating it. It is possible that surgeons have become more accustomed to the technique and improved their skills, which may have improved the cosmetic results of BCS using modified AAF.\u003c/p\u003e \u003cp\u003eThe patient evaluation indicated that patient satisfaction was high in all categories except for postoperative physical limitations. One-third of the patients experienced early postoperative strong physical limitations but generally did not encounter them more than 6 months after surgery. Immediately after the operation, the absorbable sutures can entangle the IMF, and patients often complain of skin tightness. We believe that it is important to explain before surgery that skin tightness may be felt immediately after surgery and then loosen as the absorbable sutures are absorbed.\u003c/p\u003e \u003cp\u003eOur study had several limitations. This single-center study in Japan may have limited generalizability. There was a selection bias in that fewer patients with modified AAF had tumors in the inner portion of the breast. The modified AAF technique uses the skin and subcutaneous tissue of the upper abdomen and lateral chest as flaps, and advancing the lateral thoracic tissue into the outer portion is easy. Therefore, we selected cases with good indications for tumors in the outer portion. We do not know whether more patients with tumors in the inner portion of the lesions would necessarily have the same results as those in this study. As this was a retrospective study, the criteria for selecting cases of BCS with modified AAF were not clearly defined, which may have caused selection bias. The use of the BREAST-Q to conduct patient evaluations is becoming increasingly common. However, because the BREAST-Q has a large number of questions, it could reduce the response rate of the patients. Therefore, we developed our original questionnaire using simple questions to increase patient response rates, and all patients who underwent BCS with modified AAF were evaluated using our original questionnaire, which may make it difficult to generalize the assessment.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eIn this study, BCS using the modified AAF with or without the Ochikomanai method was simpler and, therefore, less stressful for both patients and surgeons in terms of operating time, blood loss, and complications than AAF. Both cosmetic results and patient satisfaction were satisfactory. We believe that BCS using modified AAF, with or without the Ochikomanai method, is a useful technique.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with ethical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving Human Participants and/or Animals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Mie University\u0026nbsp;and\u0026nbsp;was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, 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;347:1233\u0026ndash;41. https://doi.org/10.1056/NEJMoa022152\u003c/li\u003e\n\u003cli\u003eClough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol. 2010;17:1375\u0026ndash;91. https://doi.org/10.1245/s10434-009-0792-y\u003c/li\u003e\n\u003cli\u003eSpear SL, Pelletiere CV, Wolfe AJ, Tsangaris TN, Pennanen MF. Experience with reduction mammaplasty combined with breast conservation therapy in the treatment of breast cancer. Plast Reconstr Surg. 2003;111:1102\u0026ndash;9. https://doi.org/10.1097/01.PRS.0000046491.87997.40\u003c/li\u003e\n\u003cli\u003eClough KB, Kroll SS, Audretsch W. An approach to the repair of partial mastectomy defects. Plast Reconstr Surg. 1999;104:409\u0026ndash;20. https://doi.org/10.1097/00006534-199908000-00014\u003c/li\u003e\n\u003cli\u003eChatterjee A, Gass J, Patel K, Holmes D, Kopkash K, Peiris L, et al. A consensus definition and classification system of oncoplastic surgery developed by the American Society of Breast Surgeons. Ann Surg Oncol. 2019;26:3436\u0026ndash;44. https://doi.org/10.1245/s10434-019-07345-4\u003c/li\u003e\n\u003cli\u003eYang JD, Kim MC, Lee JW, Cho YK, Choi KY, Chung HY, et al. Usefulness of oncoplastic volume replacement techniques after breast conserving surgery in small to moderate-sized breasts. Arch Plast Surg. 2012;39:489\u0026ndash;96. https://doi.org/10.5999/aps.2012.39.5.489\u003c/li\u003e\n\u003cli\u003eHamdi M. Oncoplastic and reconstructive surgery of the breast. Breast. 2013;22;Suppl 2:S100\u0026ndash;5. https://doi.org/10.1016/j.breast.2013.07.019\u003c/li\u003e\n\u003cli\u003eOgawa T, Hanamura N. Oncoplastic surgery combining abdominal advancement flaps with volume displacement techniques to breast-conserving surgery for small- to medium-sized breasts. Breast Cancer. 2016;23:932\u0026ndash;8. https://doi.org/10.1007/s12282-016-0667-6\u003c/li\u003e\n\u003cli\u003eHarris JR, Levene MB, Svensson G, Hellman S. Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast.\u003cem\u003e \u003c/em\u003eInt J Radiat Oncol Biol Phys. 1979;5:257\u0026ndash;61. https://doi.org/10.1016/0360-3016(79)90729-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast cancer, Breast-conserving surgery, Oncoplastic surgery, Reconstructive surgical procedure, Volume replacement technique","lastPublishedDoi":"10.21203/rs.3.rs-4668833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4668833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBreast-conserving surgery (BCS) of the lower portion of the breast results in poor cosmetic outcomes. Therefore, a simple and suitable technique for performing BCS for breast cancer in the lower region is needed. In 2010, we developed an abdominal advancement flap (AAF) as a simple technique. However, BCS with an AAF could have worse cosmetic results when used in older patients and those with larger breasts. Therefore, we developed the even simpler volume replacement technique based on the AAF in 2017, called the \u0026ldquo;modified AAF.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe conducted a retrospective cohort study focusing on the usefulness of the modified AAF, including cosmetic results and patient satisfaction, in 88 patients (89 breasts) who underwent BCS using the modified AAF with or without the Ochikomanai method.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTen patients had complications (11%); however, no fat necrosis was observed, and all complications improved with conservative treatment. With regard to cosmetic results, 41 breasts (58%) were rated excellent, 26 breasts (37%) were rated good, and only 4 were unacceptable, all of which were rated fair. Patients with medium- or larger-sized breasts and older patients who underwent BCS using modified AAF with or without the Ochikomanai method had acceptable cosmetic results. More than 89% of patients indicated they were somewhat or very satisfied in all eight categories, except for physical limitations in the immediate postoperative period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBCS using a modified AAF, with or without the Ochikomanai method, is a useful technique for many patients, including patients who are older or have larger breasts.\u003c/p\u003e","manuscriptTitle":"Modified abdominal advancement flap with the Ochikomanai method: Oncoplastic surgery with a simple volume replacement technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-11 05:22:15","doi":"10.21203/rs.3.rs-4668833/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1420c670-cc65-4536-a5d0-ce2ce4317d53","owner":[],"postedDate":"October 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-11T05:30:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-11 05:22:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4668833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4668833","identity":"rs-4668833","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}