38 Chapter 3 instead of 2-stage breast reconstruction.7, 13 PF preservation may thereby expand reconstructive possibilities and improve cosmetic outcomes A systematic review of the literature was initiated to evaluate the current evidence for PF preservation. The main outcome measures were oncological safety, postoperative complications such as bleeding and seroma, reconstructive complications and cosmetic outcomes. METHODS Search Strategy A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-statement (www.prismastatement.org). A comprehensive search was performed in the bibliographic databases PubMed, Embase.com and Wiley/Cochrane Library in collaboration with a medical librarian. Databases were searched from inception up to March 26, 2018. The following terms were used (including synonyms and closely related words) as index terms or free-text words: “Mastectomy,” “Breast amputation,” “Breast ablation,” “Fasciectomy,” “Fascia,” and “Pectoral.” The search was performed without date, language or publication status restriction. Duplicate articles were excluded. Cross-reference check was also performed on screened full-text articles. Study Selection Two researchers used the blinded mode on rayyan.org, the systematic review web app, to identify all prospective and retrospective studies on PF preservation, regardless of whether or not a control group was made. Only studies written in English were included. Studies that did not describe preservation of the PF in relation to complications or oncological outcomes were excluded. Case reports, case series with less than 10 patients, letters and reviews were excluded as well. All articles for which no consensus on exclusion or inclusion was reached initially were discussed. When no agreement was reached, the final decision was made in consultation with the third (senior) author. Details for the flow diagram of studies in this review are presented in Figure 1. Outcomes Oncological outcomes of interest were local recurrences, regional recurrences, distant metastasis and mortality. Local recurrence was defined as the recurrence of malignant cells in the scar, in the skin surrounding the scar or on the chest wall after complete initial tumor removal. Regional recurrences, or regional metastases, were defined as metastases located in the ipsilateral axillary lymph nodes, internal mammary nodes or infraclavicular nodes. Distant metastases were all tumor
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