9 General Introduction and outline of this thesis fasciocutaneous perforator flaps, such as the thoracodorsal artery perforator (TDAP) flap and the anterior- or lateral intercostal artery perforator (AICAP or LICAP) flap. These techniques are indicated in patients with small breasts without ptosis. The most used volume displacement technique is the Wise pattern mammoplasty with a variation in nipple areola complex pedicles. For this technique, a larger breast with some degree of ptosis is required.9-11 Mastectomy Despite the rise in the use of breast-conserving surgery, mastectomy remains indicated in a substantial part of patients with breast cancer. In 2020 in the Netherlands, 1372 patients with ductal carcinoma in situ (DCIS) underwent surgery, 67% underwent breast-conserving surgery and 31% a mastectomy. For invasive breast cancer, 10.574 patients underwent breast surgery of whom 65.2% underwent breast-conserving surgery and 34.5% received a mastectomy.12 In addition, the rates of contralateral and bilateral risk reducing mastectomy procedures have increased substantially.13, 14 Therefore, studies focusing on improving outcomes of mastectomy remain important. Over the past decades, less invasive oncological breast surgery has become increasingly popular. Halsted’s radical mastectomy, which completely removed the pectoralis major muscle (PM), was replaced by the simple mastectomy, in which the PM was spared and only the pectoral fascia (PF) was removed, with better biomechanical outcomes and fewer postoperative pain.15-17 The development of skin and nipple-sparing mastectomies and the rise of breast-conserving surgery as an oncologically safe alternative to mastectomy, are the result of a greater focus on long-term outcomes.17 The majority of those changes are the result of the awareness that more extensive surgery does not always lead to better oncological outcomes and may even harm long-term aesthetic outcomes and quality of life (QoL). In addition to the realization that more extensive surgery does not always lead to better outcomes, the following question arises: ‘is it still necessary to remove the PF during a mastectomy?’ Presently, it is common practice to routinely remove the PF during a (skin-sparing) mastectomy to guarantee tumor-free margins. However, the need for this is debatable. The PF is part of the muscular anatomy, instead of the breast glandular tissue. Therefore, other than in extremely rare cases of tumor growth into the PF, the oncological benefit of PF resection seems questionable.18 In fact, PF preservation may enhance breast reconstructive outcomes and postoperative results. It might reduce seroma formation due to its function in lymph drainage. Furthermore, postoperative bleeding and pain may be decreased by avoiding surgical injury to the PM. In addition, the PF, which is a strong fibro-elastic layer, might improve breast implant coverage.19, 20 Although the potential advantages of PF preservation seem evident, literature on this topic 1
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