Effect of lumpectomy location on the pedicle use in oncoplastic breast reductions

Introduction

Surgical management of breast cancer has undergone significant evolution over the past decade towards treatment options that are aesthetically pleasing while maintaining oncologic efficacy (1). Oncoplastic breast surgery has gained widespread acceptance as an approach that maintains cancer free margins while delivering ideal cosmetic results (2-5). Breast-conserving surgeries, including oncoplastic reductions, have several benefits over mastectomies, such as fewer operative procedures, better cosmetic outcomes, reduced complication rates, and higher patient satisfaction rates (2,6,7). These benefits are particularly pronounced in patients with macromastia, as they often suffer from higher complication rates (2). During oncoplastic breast reduction, a lumpectomy procedure is combined with a bilateral reduction mammaplasty (8-12). In patients with macromastia, this technique results in decreased postoperative morbidity, fewer corrective surgeries, and better aesthetic results compared to total reconstruction (2,13).

Oncoplastic breast reductions can be performed using the Wise pattern skin excision with a variable vascular pedicle to maintain the viability of the nipple-areolar complex (8,11,14). Following tumor excision, appropriate pedicle selection is essential for optimal oncoplastic and aesthetic outcomes (14). Depending on tumor location and the extent of tissue excision, surgeons may choose from several available pedicles. The most commonly employed pedicle is the superomedial pedicle (14,15). Alternative pedicle options include the superior pedicle, inferior pedicle, Strombeck (horizontal) pedicle, McKissock pedicle, and superolateral pedicle (14,16). The Strombeck or horizontal bipedicle uses both a medial and a lateral pedicle to supply the nipple-areolar complex (14,17). The McKissock pedicle, on the other hand, uses a vertical bipedicle technique which utilizes both the descending artery in the superior pedicle and the deep arterial system from the inferior pedicle for sufficient vascular supply to the nipple-areolar complex (14,18-20). Some pedicles may be inaccessible during oncoplastic breast reductions due to the lumpectomy site, causing surgeons to rely on other pedicles (9). While the superomedial pedicle is typically used when nipple-areolar complex blood supply remains intact, surgeons frequently employ the inferior pedicle when breast cancer involves or compromises this pedicle (9). However, comprehensive research examining optimal pedicle selection based on specific tumor locations within breast quadrants remains limited.

Another critical parameter for surgeons performing breast reductions involves anthropometric breast measurements, which offer objective, reproducible benchmarks for surgical design and assessment of surgical outcomes (21,22). Previous studies have used anthropometric breast measurements, such as sternal notch to nipple distance and nipple to inframammary fold (IMF) distance, to reliably predict breast resection weights (23,24). Similarly, previous research has employed anthropometric data to estimate breast volume and predict postoperative aesthetic outcomes (25). Despite the clinical significance of these parameters, only one prior study has quantitatively characterized the relationship between the weight of resected breast tissue and changes in specific anthropometric breast measurements (26), but did not include any patients who underwent an oncoplastic breast reduction.

Therefore, the aim of this retrospective analysis was multifaceted. First, this study aims to analyze the type of pedicle used in oncoplastic breast reductions in relation to the location of the lumpectomy site in patients from January 2021 to October 2024. Additionally, we sought to compare pedicle selection patterns in oncoplastic breast reductions with those employed in patients who underwent reduction mammaplasties. Finally, this study attempts to enhance surgical precision and patient outcomes by quantifying changes in anthropometric breast measurements based on the amount of tissue resected during surgery. We present this article in accordance with the STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-58/rc).

Methods

Study design

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The University of Alabama at Birmingham Institutional Review Board for Human Use (IRB) approved the study protocol (IRB-141105005) and individual consent for this retrospective analysis was waived. A single-center retrospective study was performed on patients who underwent breast reductions from January 2021 to October 2024 at the institution by a single surgeon. A total of 74 patients with macromastia were identified for this study. The patients were then grouped into those who underwent an oncoplastic breast reduction and those who received a reduction mammaplasty. For the purposes of this study, an oncoplastic breast reduction was defined as concurrent lumpectomy with a standard breast reduction. Exclusion criteria for the pedicle analysis included a prior mastectomy and any case in which pedicle analysis was not feasible due to the use of no pedicle (like the patient outlined in Case 1). Neoadjuvant therapy, radiation, tumor size, and tumor location relative to the nipple were not considered for inclusion or exclusion. Eighteen patients were classified as oncoplastic breast reductions and 56 were categorized as reduction mammaplasties. Relevant preoperative, perioperative, and postoperative variables were extracted through retrospective chart review, including patient demographics, family history of breast cancer, amount of breast tissue resected, pedicle type, tumor location, pathology results, nodal status, radiation status, and anthropometric breast measurements. For pedicle analysis, only the pedicle utilized in the breast undergoing lumpectomy was examined in the oncoplastic group, while bilateral pedicle types were analyzed in the reduction mammaplasty cohort. The lumpectomy side pedicle was the only pedicle analyzed in the oncoplastic reduction cohort due to an attempt to isolate the influence of tumor location on pedicle selection, as a typical reduction was performed on the non-lumpectomy breast. Anthropometric breast measurements were conducted by the senior surgeon to ensure consistency and were recorded preoperatively and postoperatively using a measuring tape and a goniometer. All postoperative measurements were taken at the two-week follow-up appointment. The measurements included breast width, nipple angle, and seven key distances: sternal notch-to-nipple, nipple-to-midline, nipple-to-IMF, axilla-to-IMF, nipple-to-axilla, nipple-to-anterior axillary line, and axilla-to-bottom of the breast. Patients were excluded from the anthropometric analysis if they had incomplete anthropometric data. Anthropometric breast measurement changes are presented as the change from preoperatively to postoperatively for every 100 g of breast tissue resected.

Statistical analysis

Normally distributed, continuous data were reported as means and standard deviations and analyzed using an unpaired t-test. Categorical data were reported as frequencies and percentages and analyzed using the chi-squared or Fisher’s Exact tests when appropriate. Fisher’s Exact, chi-squared, and t-tests were performed using GraphPad Prism software (Prism v10.2.3, GraphPad Software Inc., San Diego, CA, USA), while univariate regression was performed to analyze the anthropometric breast measurement changes for every 100 g of breast tissue resected using JMP Pro software (JMP Pro v18, JMP Statistical Discovery LLC, Cary, NC, USA). Statistical significance was set at P<0.05.

Results

Case 1

Figure 1A-1C shows preoperative photos of a patient who underwent an oncoplastic breast reduction. The patient shown in Figure 1 represents a patient who had previously undergone bilateral breast reduction prior to the oncoplastic reduction, making pedicle choice increasingly difficult. A lumpectomy weighing 25.8 g was performed on the left breast extending from the 11 o’clock position superiorly to the 2 o’clock position to remove a phyllodes tumor. A total of 248.4 g of breast tissue was removed and there was no need for a superior, medial, or inferior pedicle on the left breast; hence the patient was not included in our pedicle analysis. Concurrent tissue removal of 255.7 g from the contralateral right breast utilized a circumferential dermal pedicle for the nipple areolar complex. Figure 1D-1F shows the patient 5 months postoperatively with excellent healing and no complications.

Figure 1 Preoperative right lateral (A), left lateral (B), and anterior (C) views of a patient who underwent an oncoplastic breast reduction. Postoperative right lateral (D), left lateral (E), and anterior (F) views of the same patient 5 months after surgery.

Case 2

In contrast, the patient in Figure 2 represents a typical oncoplastic breast reduction patient without prior breast surgery and was included in the pedicle analysis. Figure 2A,2B shows views of the patient before undergoing an oncoplastic breast reduction. A lumpectomy was performed to remove a 34.3-g mass at the 8 o’clock position in the lower inner quadrant (LIQ) of the left breast. Following tissue removal, a McKissock pedicle modified to include the anterior pedicle was employed on the left breast, while a superomedial pedicle was utilized on the contralateral right breast. Pathologic examination showed no residual invasive carcinoma, with negative margins and negative nodal status in all four sentinel lymph nodes. Figure 2C,2D demonstrates excellent healing at 3 months postoperatively without complications.

Figure 2 Preoperative anterior (A) and left lateral (B) views of a patient who underwent an oncoplastic breast reduction. Postoperative anterior (C) and left lateral (D) views of the same patient three months following surgery.

Patient demographics and characteristics

Among the 74 patients included in this study, 56 patients received a reduction mammaplasty while 18 patients underwent an oncoplastic breast reduction following tumor excision. Patient demographics and characteristics are summarized in Table 1 stratified by the type of reduction. The oncoplastic breast reduction and reduction mammaplasty cohorts were well-matched across body mass index (BMI), weight, and racial distribution. Significant between-group differences were observed in patient age (P=0.003). Specifically, patients who underwent an oncoplastic breast reduction had a significantly higher age compared to those who underwent a reduction mammaplasty. Additionally, the oncoplastic breast reduction cohort had a significantly higher incidence of positive family history for breast cancer (P<0.001) compared to the reduction mammaplasty cohort.

Regarding tissue resection volumes, the total mass removed during oncoplastic procedures represented the combined weight of tissue excised during lumpectomy and the reduction component. While no statistically significant difference existed in left breast tissue removal between groups, reduction mammaplasties typically involved greater tissue excision. For the right breast, patients receiving an oncoplastic breast reduction had significantly less breast tissue removed compared to those receiving reduction mammaplasty (P=0.006).

Oncologic outcomes

Table 2 summarizes oncologic outcomes for the oncoplastic breast reduction cohort. Of the 18 patients who underwent oncoplastic reductions, one patient underwent bilateral oncoplastic breast reduction, resulting in 19 total breasts analyzed. Pathologic examination revealed 5 breasts (26.3%) with benign findings, while 14 breasts (73.6%) were confirmed as invasive ductal carcinoma. Benign findings included benign breast parenchyma, breast tissue with stromal fibrosis, apocrine metaplasia, cysts, and focal atypical hyperplasia. Lymph node status was positive in two patients (10.5%) and unknown in two patients (10.5%), while the remaining patients had negative nodal status (79.0%). Surgical margins were negative in 17 breasts (89.5%) and unknown in two breasts. Finally, adjuvant radiation treatment was administered to 9 breasts (47.4%) while 3 breasts (15.7%) did not require radiation. Radiation status remained unknown for the remaining 7 breasts.

Pedicle selection patterns

Table 3 and Figure 3 outline the pedicles used for patients receiving an oncoplastic breast reduction and those who underwent a reduction mammaplasty. In the mammaplasty cohort, the superomedial pedicle was overwhelmingly preferred, being employed in 94.6% of cases. The superior pedicle was also used in 5.4% of cases. On the other hand, the superomedial was significantly less utilized in oncoplastic breast reductions. It was used for the reduction of the left breast in 5 patients and on the right breast in 1 patient, or in a total of 6 breasts (31.6%). Notably, the superior pedicle was not utilized in any oncoplastic reduction case. The McKissock pedicle emerged as the most frequently selected option in oncoplastic reductions, being used in 4 left breast and 6 right breast cases, representing 52.6% of all oncoplastic breast reductions. The inferior pedicle was employed in 1 case each for the left and right breasts, accounting for 10.5% of all oncoplastic reductions. The Strombeck (horizontal) pedicle was used in one right breast case (5.3%).

Figure 3 Pedicle distribution in oncoplastic breast reductions.

Tumor location and pedicle selection

Table 4 and Figure 4 demonstrate the relationship between tumor location and pedicle selection in oncoplastic breast reductions. The majority of the tumors (11 cases, 57.9%) were located in the upper outer quadrant (UOQ) of the breast. Additionally, 26.3% of the tumors were in the upper inner quadrant (UIQ) and 15.8% were in the LIQ. Notably, no tumors were identified in the lower outer quadrant (LOQ) within this series of oncoplastic breast reductions. For the tumors located in the UOQ, the McKissock pedicle was selected 4 times, the superomedial pedicle 6 times, and the Strombeck (horizontal) pedicle once. When the tumor was positioned in the UIQ, the McKissock pedicle was chosen 3 times, while the inferior pedicle was selected twice. For the three patients with a tumor in the LIQ, the McKissock pedicle was consistently selected.

Figure 4 Distribution of pedicles used in oncoplastic breast reductions based on the location of the lumpectomy site. (A) The number and type of pedicles used in oncoplastic reductions stratified by the location of the tumor removed during lumpectomy. (B) Anatomical diagram of the quadrants of the breast. LIQ, lower inner quadrant; LOQ, lower outer quadrant; UIQ, upper inner quadrant; UOQ, upper outer quadrant.

Overall, in this series of oncoplastic breast reductions, the McKissock pedicle was utilized in 52.6% of cases, the superomedial pedicle in 31.6%, the inferior pedicle in 10.5% and the Strombeck pedicle in 5.3% of procedures.

Anthropometric analysis

Complete preoperative and postoperative anthropometric breast measurements were analyzed separately for each breast of 48 patients (41 reduction mammaplasty and 7 oncoplastic breast reduction patients), yielding a total number of 96 breasts for analysis. Univariate regression analysis revealed that the amount of breast tissue removed significantly influenced six of the nine key breast measurements as outlined in Table 5. Regression coefficients could not be reliably interpreted for the nipple-to-IMF (P=0.57), nipple-to-anterior axillary line (P=0.06), and nipple angle (P=0.24) measurements due to non-significant P values. Alternatively, significant findings demonstrated that for every 100 g of breast tissue removed, the sternal notch-to-nipple distance decreased by 0.7398 cm (P<0.001) and the nipple-to-midline distance decreased by 0.1560 cm (P=0.04) postoperatively. Similarly, breast width also decreased by 0.3132 cm (P<0.001). Additional significant reductions included the axilla-to-IMF distance shortening by 0.7303 cm (P<0.001), nipple-to-axilla distance decreasing by 0.3233 (P=0.04), and the axilla-to-bottom of the breast distance being reduced by 0.7694 cm (P<0.001).

Discussion

Key findings

All the patients included in this study had macromastia and underwent either an oncoplastic breast reduction or a reduction mammaplasty. The most common pedicle of choice for the reduction mammaplasty procedures was the superomedial pedicle, as it has the ability to improve upper pole fullness and breast shape (15). Additionally, using the superomedial pedicle can capitalize on the benefits of using the medial or superior pedicles individually, while also eliminating some of their downsides (14,15). This makes it desirable for breast surgery. However, due to the lumpectomy site, using the superomedial pedicle was not always possible. The dramatic reduction in superomedial pedicle use during oncoplastic procedures (31.6% vs. 94.6%) underscores the fundamental impact of tumor location on surgical planning. The superomedial was, on the other hand, often used on the breast that did not undergo the lumpectomy. On breasts that underwent a lumpectomy, the most employed pedicle was the McKissock pedicle, which has been described by previous literature (14,18,19). The McKissock pedicle’s predominance in oncoplastic cases (52.6%) reflects its strategic utility when traditional pedicles are compromised by tumor location.

Strengths and limitations

This current preliminary study possesses several strengths. First, it outlines how the site of breast cancer impacts the available pedicle options during oncoplastic breast reductions. Additionally, this study expands the quantitative model relating tissue resection volume to anthropometric breast changes, which could help provide surgeons with predictive tools for surgical planning through enhancements in future studies. This study shows that the superomedial pedicle, which was the most common pedicle used in reduction mammaplasty, was not always available for use in many of the oncoplastic breast reductions. However, this study does have some limitations. This study was a single institution and single surgeon study. Also, as previously mentioned, the size of the two groups is small. The oncoplastic breast reduction group only consisted of 18 patients, while the reduction mammaplasty group had 56 patients, limiting the clinical implications of this study. No power analysis was conducted to account for the imbalance in patient numbers, which limits the generalizability of the data. Future multi-surgeon or multi-institutional studies with larger patient populations would strengthen these findings and enable development of more robust predictive models. However, the main goal of this study was to report preliminary findings about how the preferred pedicle changed with the location of the lumpectomy compared to reduction mammaplasties. Additionally, performing pedicle analysis on both breasts in the reduction mammaplasty group while only analyzing the lumpectomy side breast in oncoplastic reduction patients could confound comparative results. This methodological approach was chosen in an attempt to isolate the influence of tumor location on pedicle selection. The anthropometric measurements were taken by a single surgeon; however intra-observer reliability could impact the reliability of the measurements taken. Additionally, the postoperative measurements were conducted at the patients’ two-week follow-up, which were impacted by the sensitivity of the breast dimensions to postoperative swelling. The variable postoperative swelling from patient to patient at the two week follow up could potentially limit the reliability of the anthropometric measurements. Anthropometric measurements were analyzed using univariate analysis. Multivariate modeling adjusting for BMI, age, pedicle type, or other related variables could enhance the use and practicality of the analysis. Moreover, aging can cause reduced skin elasticity, which could create a confounding factor that could independently influence anthropometric changes when it is not adjusted for during analysis. However, multivariate analysis was not feasible in this study due to a limited sample size. Several patients also lacked complete anthropometric measurements and were excluded from analysis. Due to the small sample size of the present study, no statistical methods such as multiple imputation were used to estimate missing values, introducing another limitation of the anthropometric values. Future multi-surgeon and multi-institutional studies with larger sample sizes could apply imputation to prevent data loss or potential bias.

Comparison with similar research

Another area of interest for our study was the demographics of the two cohorts. It is commonly known that the risk for breast cancer increases with age (27-31). Additionally, a family history of breast cancer also likely increases the risk for developing breast cancer (27-31). The patients in the oncoplastic breast reduction group had a significantly higher age compared to those who received a reduction mammaplasty. Similarly, the oncoplastic breast reduction group also had a much higher incidence of a family history of breast cancer (61% vs. 16%). Both statistics are in line with the expected risk factors.

There was no significant difference in the weight of the oncoplastic breast reduction cohort compared to the patients undergoing a reduction mammaplasty. Similarly, there was no statistical significance in the BMI of the patient groups as well. Previous medical research suggests that increased weight often increases the risk for breast cancer (27-31), and our groups do not contradict this trend. Although it was found that oncoplastic breast reduction patients had a lower weight and BMI on average compared to the reduction mammaplasty group, likely due to a lack of sample size for the oncoplastic reduction cohort. This discrepancy in the number of patients in each group is expected though as reduction mammaplasties are more commonly performed than oncoplastic breast reduction procedures.

Explanation of findings

Our univariate regression analysis revealed significant correlations between the weight of the breast tissue excised and six of the nine anthropometric breast measurements assessed in this study, including breast width, sternal notch to nipple, nipple to midline, axilla to IMF, nipple to axilla, and axilla to the bottom of the breast. This study adds additional anthropometric breast measurements and expands upon the quantitative modeling of the relationship between tissue resection volume and breast dimensional changes first outlined by Smithson et al. (26). For every 100 g of breast tissue resected, significant reduction was found in the sternal notch-to-nipple, axilla-to-IMF, and axilla-to-bottom of the breast distances. The breast width, nipple-to-midline, and nipple-to-axilla measurements were also found to be significantly reduced for every 100 g of tissue resected. By establishing these quantitative relationships, surgeons can better predict postoperative breast contour and optimize surgical planning to achieve desired aesthetic outcomes in both reduction mammaplasty and oncoplastic breast reduction.

Implications and actions needed

Surgical literature has described oncoplastic breast reductions as a reliable reconstructive technique after breast conserving surgery (BCS) (2,32). It has been found to have fewer complications, lower rates of re-excision, and better cosmetic outcomes than BCS lacking the plastic surgery techniques found in oncoplastic breast reductions (33,34). Additionally, compared to mastectomy, oncoplastic breast reductions require fewer revisions, have lower rates of morbidity, and have great patient satisfaction with the aesthetic outcomes (2,13). This preliminary study demonstrates that the superomedial pedicle is preferred in reduction mammaplasties but is often unavailable in oncoplastic procedures due to tumor location, necessitating alternative pedicle selection. The prevalence of the McKissock pedicle in the oncoplastic reduction cases outlined in this study may demonstrate its strategic utility when traditional pedicles are compromised by tumor location. Additionally, the quantified relationship between tissue resection and anthropometric changes could provide valuable data for surgical planning. Future enhancement of this predictive data can extend beyond improving postoperative aesthetic outcomes and optimize tissue resection based on anthropometric projections to improve functional outcomes, especially in patients with macromastia.

Conclusions

Oncoplastic breast reduction continues to be a viable option for patients undergoing breast surgery that prioritizes optimal aesthetic and oncological outcomes. The pedicle design during oncoplastic breast reduction is vital to maximize the vascularity and sensation to the nipple. This retrospective review aimed to present preliminary findings on the effect of the lumpectomy site on the pedicle used during oncoplastic breast reduction and how that compares to the pedicles used in reduction mammaplasty. The McKissock pedicle was the most commonly used pedicle in breasts that underwent a lumpectomy at 52.6%, while the superomedial pedicle was used in 94.6% of patients that had a reduction mammaplasty, which was considerably higher than its use in oncoplastic breast reductions. This study expands upon the quantitative relationship between tissue resection volume and anthropometric breast measurements, which could help provide surgeons with evidence-based tools for surgical planning. With the increased popularity and familiarity of oncoplastic breast reductions, more research is needed to determine the optimal pedicle choice during surgery. Future research should focus on multi-surgeon and multi-institutional validation and development of comprehensive predictive models to further enhance surgical precision and patient outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-58/rc

Data Sharing Statement: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-58/dss

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-58/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-58/coif). S.S.C. serves as an unpaid editorial board member of AME Surgical Journal from April 2025 to March 2027. She declares that she holds a UAB Internal grant on skin cancer margins, and is a paid medical consultant for Avita Medical, and was paid for a deposition related to a burn patient last year; all these activities are unrelated to the current manuscript. Additionally, a patent has been applied for, also unrelated to this paper. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board for Human Use of the University of Alabama at Birmingham (IRB-141105005) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bertozzi N, Pesce M, Santi PL, et al. Oncoplastic breast surgery: comprehensive review. Eur Rev Med Pharmacol Sci 2017;21:2572-85.
2. Benedict KC, Brown MI, Berry HA, et al. Oncoplastic Breast Reduction: A Systematic Review of Postoperative Complications. Plast Reconstr Surg Glob Open 2023;11:e5355. [Crossref] [PubMed]
3. Piper ML, Esserman LJ, Sbitany H, et al. Outcomes Following Oncoplastic Reduction Mammoplasty: A Systematic Review. Ann Plast Surg 2016;76:S222-6. [Crossref] [PubMed]
4. Yiannakopoulou EC, Mathelin C. Oncoplastic breast conserving surgery and oncological outcome: Systematic review. Eur J Surg Oncol 2016;42:625-30. [Crossref] [PubMed]
5. Losken A, Smearman EL, Hart AM, et al. The Impact Oncoplastic Reduction Has on Long-Term Recurrence in Breast Conservation Therapy. Plast Reconstr Surg 2022;149:867e-75e. [Crossref] [PubMed]
6. Chan SW, Cheung PS, Lam SH. Cosmetic outcome and percentage of breast volume excision in oncoplastic breast conserving surgery. World J Surg 2010;34:1447-52. [Crossref] [PubMed]
7. Nijenhuis MV, Rutgers EJ. Who should not undergo breast conservation?. Breast 2013;22:S110-4.
8. Chang MM, Huston T, Ascherman J, et al. Oncoplastic breast reduction: maximizing aesthetics and surgical margins. Int J Surg Oncol 2012;2012:907576. [Crossref] [PubMed]
9. Lee JH, Ryu JY, Choi KY, et al. Useful Reduction Mammoplasty Technique in Oncoplastic Breast Surgery and Reconstruction. Breast J 2022;2022:2952322. [Crossref] [PubMed]
10. Pillarisetti RR, Querci Della Rovere G. Oncoplastic breast surgery. Indian J Surg 2012;74:255-63. [Crossref] [PubMed]
11. Piper M, Peled AW, Sbitany H. Oncoplastic breast surgery: current strategies. Gland Surg 2015;4:154-63. [Crossref] [PubMed]
12. Rancati A, Angrigiani C, Dorr J, et al. Oncoplastic breast reduction in conservative surgery. Minerva Chir 2018;73:334-40. [Crossref] [PubMed]
13. Losken A, Pinell XA, Eskenazi BR. The benefits of partial versus total breast reconstruction for women with macromastia. Plast Reconstr Surg 2010;125:1051-6. [Crossref] [PubMed]
14. Wong C, Vucovich M, Rohrich R. Mastopexy and reduction mammoplasty pedicles and skin resection patterns. Plast Reconstr Surg Glob Open 2014;2:e202. [Crossref] [PubMed]
15. Brown RH, Siy R, Khan K, et al. The Superomedial Pedicle Wise-Pattern Breast Reduction: Reproducible, Reliable, and Resilient. Semin Plast Surg 2015;29:94-101. [Crossref] [PubMed]
16. Cárdenas-Camarena L, Vergara R. Reduction mammaplasty with superior-lateral dermoglandular pedicle: another alternative. Plast Reconstr Surg 2001;107:693-9. [Crossref] [PubMed]
17. Fournier PF. Strombeck Breast Reduction Technique. In: Shiffman MA, Di Giuseppe A, editors. Body Contouring: Art, Science, and Clinical Practice. Berlin, Heidelberg: Springer Berlin Heidelberg; 2010. p. 155-67.
18. Abozeid MF, Tahseen H, Kenawi I. McKissock's Reduction Mammaplasty Revisited: A Case Series Study with 12-months Follow-up. Plast Reconstr Surg Glob Open 2018;6:e1791. [Crossref] [PubMed]
19. Menderes A, Mola F, Vayvada H, et al. Dermal suspension flaps for McKissock's vertical bipedicle flap vs. classical McKissock's technique: comparison of aesthetic results and patient satisfaction. Br J Plast Surg 2005;58:209-15. [Crossref] [PubMed]
20. Messana F, Grigatti M, Budini V, et al. The McKissock's technique in reduction mammaplasty: A comparative study of outcomes and complications in 211 consecutive patients. Front Surg 2022;9:970381. [Crossref] [PubMed]
21. Choppin SB, Wheat JS, Gee M, et al. The accuracy of breast volume measurement methods: A systematic review. Breast 2016;28:121-9. [Crossref] [PubMed]
22. Mikołajczyk M, Kasielska-Trojan A, Antoszewski B. A New Tool for Breast Anthropometric Measurements: Presentation and Validation for Women and Men. Aesthetic Plast Surg 2019;43:1160-70. [Crossref] [PubMed]
23. Kececi Y, Sir E. Prediction of resection weight in reduction mammaplasty based on anthropometric measurements. Breast Care (Basel) 2014;9:41-5. [Crossref] [PubMed]
24. Li H, Lin Y, Li Z, et al. A Predictive Model for Breast Tissue Resection Weight in Vertical-Scar Reduction Mammoplasty. Aesthetic Plast Surg 2025;49:4006-12. [Crossref] [PubMed]
25. Muslu Ü, Demir E, Özdemir F, et al. Investigation of the Anthropometric Changes in Breast Volume and Measurements After Breast Reduction. Cureus 2019;11:e4312. [Crossref] [PubMed]
26. Smithson MG, Collawn SS, Mousa MS, et al. A Formula for Planning and Predicting Postoperative Mammoplasty Results. Ann Plast Surg 2017;78:S343-6. [Crossref] [PubMed]
27. Anothaisintawee T, Wiratkapun C, Lerdsitthichai P, et al. Risk factors of breast cancer: a systematic review and meta-analysis. Asia Pac J Public Health 2013;25:368-87. [Crossref] [PubMed]
28. Britt KL, Cuzick J, Phillips KA. Key steps for effective breast cancer prevention. Nat Rev Cancer 2020;20:417-36. [Crossref] [PubMed]
29. Michaels E, Worthington RO, Rusiecki J. Breast Cancer: Risk Assessment, Screening, and Primary Prevention. Med Clin North Am 2023;107:271-84. [Crossref] [PubMed]
30. Momenimovahed Z, Salehiniya H. Epidemiological characteristics of and risk factors for breast cancer in the world. Breast Cancer (Dove Med Press) 2019;11:151-64. [Crossref] [PubMed]
31. Rojas K, Stuckey A. Breast Cancer Epidemiology and Risk Factors. Clin Obstet Gynecol 2016;59:651-72. [Crossref] [PubMed]
32. Losken A, Hart AM, Broecker JS, et al. Oncoplastic Breast Reduction Technique and Outcomes: An Evolution over 20 Years. Plast Reconstr Surg 2017;139:824e-33e. [Crossref] [PubMed]
33. Crown A, Scovel LG, Rocha FG, et al. Oncoplastic breast conserving surgery is associated with a lower rate of surgical site complications compared to standard breast conserving surgery. Am J Surg 2019;217:138-41. [Crossref] [PubMed]
34. Crown A, Wechter DG, Grumley JW. Oncoplastic Breast-Conserving Surgery Reduces Mastectomy and Postoperative Re-excision Rates. Ann Surg Oncol 2015;22:3363-8. [Crossref] [PubMed]