21 Outcomes following oncoplastic breast surgery good, 4: excellent), for each of the following four categories: mammary symmetry, scarring, areola-nipple symmetry and global judgment. The score and cosmetic categories were derived from previous research.18 In case the patient underwent a contralateral symmetrization, patients were asked to fill in these questions according to the situation before the symmetrizing surgery. Patients in whom the nipple was excised, the nipple areolar symmetry was not scored. Panel reported cosmetic outcomes In accordance with the standard postoperative protocol after breast reconstruction, five-point view medical photographs were made at a minimum of three months after the surgery and uploaded in the patient files. In case these photographs were not present in the patient files, patients were invited for an appointment with the medical photographer. Based on these photographs, cosmetic outcomes were evaluated by a panel consisting of two independent plastic surgeons and two laymen. The members of the panel scored cosmetic outcomes independently and were blinded for any clinical information. All members of the panel were invited to evaluate the breasts in the previously mentioned four categories with a score from 1-4. Patients who underwent a contralateral symmetrization without available photographs before this procedure, were excluded from the analysis. The nipple areolar symmetry was not scored if the nipple was excised during OPS. Statistical analysis Continuous variables are presented as median values with interquartile ranges (IQRs) and frequency percentages were calculated for categorical variables. Differences in baseline characteristics between groups were tested with MannWhitney U tests, chi-square tests or Fisher’s exact tests. Comparisons between volume displacement and volume replacement techniques were performed using the chi-square test for postoperative complications and Mann-Whitney U test for BREAST-Q and cosmetic outcomes. The same tests were performed for comparisons between patients with and without complications. Patients with missing data on (domains of) the BREAST-Q or cosmetic outcomes were excluded from this specific part of the analysis. The level of inter-observer agreement between the two laymen and the two specialists was derived from Cohen’s kappa values and defined as follows: 0-0.20 slight agreement, 0.21-0.40 fair agreement, 0,41-0.60 moderate agreement, 0.61-0.80 substantial agreement and 0.81-1 excellent agreement. A two-sided P-value of <0.05 was considered statistically significant. IBM SPSS statistics (version 26) was used for standard statistical analysis. 2
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