59 Pectoral fascia preservation in mastectomy with immediate reconstruction respondents, 57% believes that PF preservation may improve implant coverage, 44% believes that it may reduce postoperative complications and 28% thinks that it may improve cosmetic outcomes. Literature shows that the PF could be a valuable aid for implant coverage, since it is a thin but strong fibroelastic layer.7 The PF is even used as a layer to cover the breast implant in a subfascial way, emphasizing its strength.8, 9 Furthermore, it could be hypothesized that preservation of the PF reduces postoperative complications, as 50% of postoperative hemorrhage requiring surgery originates from the PM.10 Moreover, seroma is mainly caused by muscle damage. One study on PF preservation indeed found a decrease in postoperative seroma formation.5 The main reason why the PF was never preserved according to the respondents of both surveys was because of oncological safety, although there is no proof of this statement in the current literature.6 Thereby, according to the breast surgeons, circa one in five responded that the PF was preserved only in those cases when the tumor is located on a safe distance from the fascia, which varied between 1 mm and 2 cm. This implies that there is no consensus regarding the definition of this ‘safe distance’. If the oncological safety would be compromised by PF preservation, this should result in an increased rate of chest-wall recurrences, caused by invasion in the PF. However, previous studies show that chest-wall recurrences are rare, with an incidence of 0.97-1.68%.11, 12 A previous trial comparing PF preservation with PF removal found no significant differences in oncological outcomes (local recurrence, regional recurrence or distant metastasis).13 However, several studies have shown that PF invasion can occur when tumors are located within 5 millimeters of the PF, and is unlikely to occur with more than five millimeters distance.4, 14 This suggests that a tumor-fascia distance of more than 5 mm could be interpreted as safe.6 Another important reason why the PF was never preserved according to the breast surgeons was because they are not familiar with this technique. However, although the PF and the PM muscle should be considered together as one myofascial unit, excision of the PF is not the most understandable choice from a surgical technical point of view.6, 7 Moreover, at least one third of the Dutch breast surgeons already uses this PF preserving technique. The strength of this study is that the surveys were sent to all plastic surgeons and breast surgeons with respondents operating in the majority of Dutch medical centers, which implies that this study provides a valuable overview of handling of the PF during mastectomies in the Dutch practice. 4
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