119 General discussion and future directions As patients are overall very satisfied with their results after OPS, all eligible patients should be counseled for an oncoplastic reconstruction, even though more extensive surgery could lead to more complications. In accordance with the literature, chapter 2 of this thesis highlighted how surgical complications are negatively associated with patient satisfaction and other patient-reported outcomes in patients after OPS. The importance of providing the patient with extensive information concerning all possible outcomes was emphasized, especially regarding the influence of related complications. Future research should focus on better preoperative counseling strategies and how additional information following the consultation per individual could be optimized. Pectoral fascia preservation The surgical technique of mastectomy has undergone significant changes in time and has become less and less extensive. Today, the majority of patients can undergo nipple or skin sparing mastectomies, offering patients enhanced cosmetic results without compromising the oncological safety.6 Although removal of the pectoralis major (PM) muscle has long been outdated, routine excision of the pectoral fascia (PF) is still part of the current technique. Chapter 3 of this thesis consists of a systematic review concerning preservation of the PF in oncological mastectomies.7 Based on the five studies in the review, PF preservation appears to be an oncologically safe procedure, it might reduce postoperative seroma, infection rates, implant extrusion, and bleeding complications, while improving cosmetic outcomes. Unfortunately, the evidence in the available literature is weak since the included studies 8-12 have heterogeneous patient populations with relatively small patient groups, lacking high quality data to support these statements. Since the systematic review, a few new studies have been published investigating this topic. Mohamed et al. conducted a randomized controlled trial (RCT) with a total number of 101 patients and found a significantly lower cumulative seroma volume in patients who had PF preservation, compared to patients with PF excision. No significant differences in oncological outcomes were found between the groups.13 Furthermore, in one other study the PF is advocated as the preferred coverage of an implant over an acellular dermal matrix (ADM) in pre-pectoral reconstruction.14 Another recent review, which summarized common dissection planes for mastectomies, reported it is unusual to detect breast ducts or glandular tissue beyond the dorsal fascia of the breast, so removing the fascia is not routinely performed and depends on the tumor location and degree of muscle invasion. Furthermore, the authors of this review point out PF preservation might decrease surgical complications, but that there is a lack of consensus about the need of removal, unless it is necessary to achieve clear margins.15 8
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