55 Pectoral fascia preservation in mastectomy with immediate reconstruction INTRODUCTION Although breast-conserving surgery has gained popularity over the past decades, mastectomy remains indicated in a substantial part of breast cancer patients. In 2019, a mastectomy was performed in 31.4% of patients with invasive breast cancer and in 25.9% of patients with ductal carcinoma in situ in the Netherlands.1 Furthermore, there is a notable rise in contralateral and bilateral prophylactic mastectomies.2, 3 Thus, studies toward improving outcomes of mastectomies remain relevant. During a skin sparing mastectomy, removal of the pectoral fascia (PF) is widely performed. However, its necessity to do so is questionable. Historically, the PF was excised to ensure that no remnant breast tissue was left behind. However, the PF is part of the muscular anatomy instead of the breast glandular tissue. Therefore, the oncological benefit of PF excision is unlikely, except in rare cases of tumor invasion into the PF.4 In fact, PF preservation may improve postoperative and breast reconstructive outcomes. It prevents surgical damage to the pectoralis major muscle (PM), thereby possibly enhancing breast implant coverage, and decreasing seroma formation, postoperative bleeding and pain.5 It has been hypothesized that PF preservation may reduce re-operation rates and improve cosmetic outcomes.6 Although the potential benefits of PF preservation seem evident, the literature on this subject is scarce. Previous studies described heterogeneous outcomes based on small samples.4 For this reason, there is currently insufficient evidence to support implementation of PF preservation as the standard approach in the national guidelines. Here we report on a national survey in which attitudes on PF preservation among Dutch breast surgeons and plastic surgeons were studied. METHODS A survey based study was performed, in which both plastic surgeons and oncological breast surgeons were included, each receiving a different version of the survey. The surveys were distributed through the Dutch Society of Plastic Surgery (NVPC) and the Dutch Society of Surgical Oncology (NVCO). In the Netherlands it is required for all plastic surgeons and breast surgeons (i.e. all oncological surgeons specialized in oncological breast surgery) to be a member of the NVPC or NVCO. Because no patients were involved, no permission of a medical ethics committee or informed consent was required. The survey for the plastic surgeons was sent twice to 460 e-mail addresses by the NVPC with a three-week time interval. The survey for the breast surgeons 4
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