Results
In the present study, 107 patients were enrolled. The mean age of the study population was 48.49±9.22 years, with the majority 95 (88.8%) being <60 years of age. The majority of the patients were married 97 (90.65%), and a substantial proportion 77 (72.0%) were non-smokers. As regards surgical history, 8 (7.5%) patients had previously undergone breast surgery, while 99 (92.5%) had not. In terms of occupation status, 20 (18.69%) were employed, whereas 82 (76.64%) were housewives. The majority of the patients (n=90, 84.11%) had received chemotherapy (Table I).
Tumor laterality was virtually evenly distributed, with 54 (50.47%) of tumors occurring on the right side and 52 (48.60%) in the left. The most common tumor location, as determined by ultrasound, was the upper outer quadrant 56 (52.34%), followed by the upper inner quadrant 20 (18.69%). As regards tumor size, the majority 56 (52.3%) of tumors measured between 10-20 mm. Pathologically, invasive ductal carcinoma was the predominant diagnosis, accounting for 61 (57.0%) of cases. Fine needle aspiration results revealed that 36 (33.64%) of cases were positive, whereas 71 (66.36%) were negative (Table II).
The median tumor size was 2.0 cm (range, 1.5-2.7 cm). The majority of tumors were classified as grade II 73(68.22%), followed by grade III 26(24.30%). Reoperative surgery was required in 10 (9.35%) of cases, with a wide local excision being the most common reoperation 7 (70.0%). As regards post-operative surgical margins, 95 (88.78) of the patients had negative margins. TNM staging revealed that the majority of patients were classified as stage II 61 (57.0%). Among the post-operative complications, shoulder stiffness was the most common complication reported in 27 (25.23%) of the patients, followed by infection in 26 (24.30%) cases (Table III). All assessed variables had high mean satisfaction scores, >8.0. The highest overall mean score was for shape (8.87±1.50), followed by size (8.76±1.78). Among the quadrants, the lower inner quadrant had the highest mean scores for both size (9.83±0.41) and shape (9.83±0.41). Nipple-areolar position and appearance had mean scores of 8.45±1.78 and 8.42±1.75, respectively (Table IV).
Across tumor grades (grade 0, n=3; grade I, n=4; grade II, n=73; grade III, n=26; NA, n=1; total n=107), post-operative complications were generally infrequent, and Fisher's exact test revealed no statistically significantly differences between the groups. Bleeding was absent in patients with grade 0 and I (0.0%) tumors, and occurred in 4.1% (3/73) of patients with grade II and 7.7% (2/26) of patients with grade III tumors (P=0.734). Hematoma exhibited a similar pattern, being absent in patients with grade 0 and I tumors, and present in 8.2% (6/73) and 7.7% (2/26) of patient with grade II and III tumors, respectively (Fisher's exact test, P=0.951). Patient satisfaction scores remained high across all tumor grades without significant differences. Median breast shape scores ranged from 8.0 to 10.0, with 10.0 (8-10) in patients with grade II and 9.0 (8-10) in patients with grade III tumors (P=0.289). Nipple-areolar position and appearance scores were similarly high, with medians of 9.0-10.0 in patients with grade II-III tumors compared to slightly lower values in those with grade I tumors (P=0.702 and P=0.925, respectively). Breast symmetry and overall breast appearance exhibited median scores between 8.0 and 10.0 across groups (P=0.838 and P=0.595, respectively), while scar appearance and skin sensitivity also remained favorable, with median values predominantly between 8.0 and 9.0 (P=0.773 and P=0.645, respectively) (Table V).
Discussion
The incidence of breast cancer among younger populations has been steadily increasing, with the American Cancer Society reporting an annual increase of ~0.6-1%, particularly among young adults (8). This trend underscores the need for further research into the underlying causes, risk factors and innovative surgical strategies for the disease. Recent studies have introduced novel oncoplastic breast-conserving techniques targeting younger patients. Shi et al (9) reported that 86.5% of patients undergoing the folding flap technique were <60 years of age, while Chen et al (10) found that 67.2% of patients treated with the spoon-shape technique were <60 years. Consistent with these findings, the present study evaluating the ‘umbrella’ technique demonstrated that 88.8% of the 107 enrolled patients were <60 years of age, with a mean age of 48.49 years, highlighting the growing relevance of oncoplastic innovations for younger breast cancer populations.
The Surveillance, Epidemiology, and End Results program reports a slight predominance of left-sided breast cancer, with a laterality ratio of 1.041(11), a pattern also observed in triple-negative breast cancer, where left-sided tumors accounted for 69.12% of cases (12). By contrast, a retrospective study evaluating a retroglandular oncoplastic technique reported a predominance of right-sided tumors (57.8%) (13). In the present study, tumor laterality was almost balanced, with 50.47% occurring in the right breast and 48.60% in the left. As regards tumor size, previous studies using ultrasound-based evaluation reported that the majority of tumors measured 20-45 mm (55.2%) or 20-40 mm (65.4%) (9,10). Conversely, the present study found that 60.75% of tumors were <20 mm in size, including 8.4% measuring 1-10 mm and 52.3% measuring 10-20 mm.
Oncoplastic breast surgery expands the indications for reconstructive breast cancer procedures and provides an alternative to mastectomy; however, aesthetic outcomes may not be satisfactory for all patients (14). Of note, >80% of patients undergoing oncoplastic surgery report they would opt for the same procedure again, reflecting greater satisfaction with cosmetic outcomes and self-esteem compared with traditional surgical approaches. Nevertheless, patients treated with oncoplastic techniques often have greater expectations than those undergoing conventional breast-conserving surgery, largely due to the reduced risk of post-operative deformities (15,16). Tumor excision in areas covered by classic surgical patterns remains challenging. Previous studies have demonstrated that 51.5% of tumors are located in the upper-outer quadrant, followed by the upper-inner (15.6%), lower-outer (14.2%), central (10.6%) and lower-inner (8.1%) quadrants (17), with tumors occurring more frequently in the upper and far breast regions (16). Consistent with these reports, the majority of tumors in the present study were located in the upper breast regions, where existing oncoplastic techniques, despite their availability, continue to present technical challenges.
Breast size plays a crucial role in determining the appropriate oncoplastic surgical approach. For patients with relatively large breasts, level II oncoplastic breast surgery, which follows a reduction-based technique, is often the preferred option. However, in cases where patients wish to maintain their breast size, preserve symmetry, or avoid extensive surgery, level I is more suitable. In such instances, as well as in patients with medium-sized breasts, volume displacement techniques generally provide sufficient residual tissue to achieve favorable cosmetic outcomes (16,18). Even under these conditions, the ‘Umbrella’ Technique may be a preferable option, as it minimizes the extent of the procedure, while reducing the risk of post-operative asymmetry.
The distribution of glandular tissue varies across breast quadrants, which has led to the development of surgical incisions tailored to tumor location. Resecting tumors in the upper inner quadrant of the breast presents critical challenges due to the aesthetic importance of this area to patients. Consequently, there is a pressing need for innovative surgical approaches that mitigate the limitations of existing techniques (16). The findings of the present study indicate that the ‘umbrella’ technique provides multiple advantages, positioning it as a viable alternative to conventional surgical methods for upper inner quadrant tumors, while preserving the nipple-areolar complex.
The batwing incision, commonly used for tumors in the upper-inner quadrant, involves two circular incisions, de-epithelialization, and repositioning of the nipple-areola complex. This approach carries the risk of shifting the nipple-areola complex to one side or causing asymmetry in the breast (19). Although several other innovative approaches, such as crescent, hemi-batwing excisions and modified round-block mammoplasty, have been reported to be effective with good esthetic results (20), there has not been a standard oncoplastic procedure for this area, at least to the best of our knowledge. In the present study, 20 tumors (18.69%) were located in the upper-inner quadrant. Following the procedure, patient satisfaction was evaluated based on nipple-areola positioning, nipple-areola appearance and overall breast symmetry. All patients reported high satisfaction, with mean scores of 8.05, 7.90 and 7.95, respectively. These positive outcomes highlight the effectiveness of the ‘umbrella’ technique, which was employed in the present study. The ‘umbrella’ technique features a more versatile incision that extends towards the periphery of the breast, providing several advantages over traditional methods. This incision design allows for more controlled tumor resection, enabling precise excision, while preserving the nipple-areola complex and overall breast symmetry. This technique also minimizes tissue disruption, reducing the risk of complications such as nipple displacement. By maintaining the natural contour of the breast, this technique markedly improves aesthetic outcomes.
The fusiform incision is commonly used for tumors in the upper-outer quadrant, as it follows natural skin folds. Its tapered corners minimize wound tension, promoting better healing. However, in the event that the defect is not adequately filled, skin retraction may occur. Additionally, in cases of peri-areolar tumors, this technique can lead to significant asymmetry with the contralateral breast (21). By contrast, the ‘umbrella’ technique, employed in the present study, provides several advantages, particularly in terms of aesthetic outcomes and reconstruction. By using controlled tissue dissection and a rotational flap, the ‘umbrella’ technique provides better symmetry and contour restoration, even for more complex tumor locations, such as the upper-inner quadrant, where 52.3% of the tumors in the present study were located. This technique effectively reduces skin tension, minimizing the risk of wound dehiscence and promoting improved healing. Furthermore, it adapts well to larger or more central defects, providing superior cosmetic results compared to the fusiform incision. Patient satisfaction for tumors in the upper outer quadrant in the present study was evaluated based on shape, nipple-areola positioning, breast symmetry and scar appearance. The results revealed high patient satisfaction with the ‘umbrella’ technique, reflected by mean scores of 8.72, 8.40, 7.81, and 8.55, respectively.
The fish-hook-shaped incision is generally preferred for tumors in the lower-inner quadrant, particularly in patients with larger breasts; however, it often results in long scars that may compromise cosmetic outcomes (22). The J incision is commonly applied to lower-outer quadrant tumors; however, it may produce characteristic ‘bird's beak’ deformities (23). By contrast, the ‘umbrella’ technique provides greater versatility across multiple tumor locations, including the upper-inner and central quadrants and facilitates improved symmetry restoration. By minimizing skin tension through controlled dissection and rotational flap design, this technique enhances contour preservation and scar management, resulting in superior aesthetic outcomes compared with fish-hook and J incisions, which are more limited in achieving optimal cosmetic results. In the present study, 21 tumors (19.63%) were located in the lower-inner or lower-outer quadrants, where fish-hook and J incisions are typically employed. Patient satisfaction with the ‘umbrella’ technique, assessed in terms of breast shape, nipple-areola position, symmetry, overall appearance and scar quality, was high. The mean satisfaction scores for the lower-inner quadrant were 9.83, 9.50, 9.33, 9.17 and 9.00, respectively, while corresponding scores for the lower-outer quadrant were 9.27, 8.87, 8.73, 8.73 and 9.13. These findings highlight the ‘umbrella’ technique's superior aesthetic performance and patient satisfaction compared with conventional fish-hook and J incisions.
Breast-conserving surgery carries an inherent risk of incomplete resection and positive margins. When post-operative pathological examination reveals a positive margin, re-excision and further resections become necessary. Previous studies have indicated that the incidence of positive margins following oncoplastic breast surgery ranges from 7 to 12% (23,24). In the present study, post-operative surgical margin analysis revealed that only 7.48% of cases exhibited positive margins, which aligns with the lower end of the reported range (7-12%) in the literature (23,24). Due to the considerable displacement of breast tissue often observed in oncoplastic procedures, precisely identifying the involved margin during re-excision can be technically challenging (16). However, with the technique introduced, if additional surgery is required to achieve clear margins, reopening the breast and performing the re-excision is not a particularly difficult procedure.
The complication rates observed in the present study, including an infection rate of 24.3% and a tissue necrosis rate of 15.0%, are higher than those typically reported for standard breast-conserving surgery (<5%) and warrant careful consideration. Several patient- and technique-related factors likely contributed to these findings. First, the majority of patients in the present study cohort (84.1%) received neoadjuvant chemotherapy prior to surgery, a well-established risk factor for impaired wound healing and increased susceptibility to post-operative infection (25). Second, the ‘umbrella’ technique was preferentially applied to technically demanding cases, including tumors in the upper-inner quadrant, larger resections and lesions in proximity to the axilla; the latter location is associated with higher rates of local bacterial colonization and infection (26). Third, the technique involves extensive three-plane glandular dissection and flap redistribution, which inherently increases the risk of seroma formation, local ischemia, and partial tissue necrosis. Notably, the majority of complications were minor and managed conservatively, without compromising the overall reoperation rate (9.35%) or patient satisfaction scores, which remained consistently high across all evaluated domains.
The elevated infection and tissue necrosis rates observed in the present study cohort, although higher than those typically reported for standard breast-conserving surgery, are consistent with the increased technical complexity and patient-related risk factors inherent to oncoplastic procedures. Upper-inner quadrant oncoplastic surgery, which accounted for 18.69% of cases, has been shown to be associated with complication rates of up to 25%, including wound dehiscence, seroma, infection and marginal skin necrosis (27). Similarly, another study reported a complication rate of 10.8% in the upper-inner quadrant resections, even in the absence of neoadjuvant chemotherapy (28). In higher-complexity level II oncoplastic procedures, complication rates of ~25% have been described, with major complications occurring in 5-9% of cases, which aligns with the current reoperation rate of 9.35% (29). As regards neoadjuvant chemotherapy, the systematic review and meta-analysis by Lorentzen et al (30) reported a consistent, although non-significant, trend toward higher rates of wound complications, skin/nipple necrosis and flap ischemia in neoadjuvant chemotherapy-treated patients. In addition, another study with a large patient series identified neoadjuvant chemotherapy as an independent predictor of wound healing complications (odds ratio, 2.9; P=0.02) and fat necrosis (odds ratio, 2.8; P<0.01) following breast reconstruction (31), supporting the morbidity pattern observed in the present study cohort.
To reduce complications in future applications of the ‘umbrella’ technique, several measures may be considered. These include strict preoperative optimization (nutritional status, glycemic control and smoking cessation), the appropriate timing of surgery following neoadjuvant chemotherapy (minimum 4-6 weeks), tailored antibiotic prophylaxis in axillary-adjacent dissections, the routine use of closed-suction drains in extensive glandular mobilization, and selective intraoperative perfusion assessment using indocyanine green angiography to identify poorly vascularized tissue prior to closure. These strategies may help reduce infection, seroma formation and tissue necrosis in future series.
The present study has several limitations that should be acknowledged. First, the retrospective design and single-institution setting may introduce selection bias and limit the generalizability of the findings to other centers. Second, the study period of 1 year and the restriction to patients with early-stage breast cancer may not fully represent the broader spectrum of patients who could benefit from the ‘umbrella’ technique. Third, although post-operative complications and patient-reported aesthetic satisfaction were systematically recorded, the use of a non-validated 1-10 satisfaction scale instead of established Patient-Reported Outcome Measures (PROMs), such as the BREAST-Q, represents a methodological limitation and may introduce subjective bias; future prospective studies are thus required to incorporate such instruments to provide a more comprehensive evaluation of patient outcomes. Fourth, the ‘umbrella’ technique requires a high level of surgical expertise and familiarity with both oncological and reconstructive principles; therefore, its adoption in other institutions should be accompanied by structured training programs and mentorship to ensure safe and effective implementation. Fifth, the technique presents inherent challenges in specific patient subgroups, including those with centrally located tumors, highly aggressive cancer subtypes, or a prior history of breast surgery, and these should be considered carefully during patient selection. Finally, the absence of long-term follow-up represents a notable limitation, as the long-term prognosis, including recurrence rates, survival outcomes and potential metastasis, was not assessed. Future studies are thus warranted to incorporate extended follow-up periods to more comprehensively evaluate the oncological impact of the procedure and provide a more complete understanding of its effect on patient prognosis.
In conclusion, the present study demonstrates that the ‘umbrella’ technique overcomes limitations of traditional breast-conserving procedures, particularly for tumors in sensitive areas. It provides clear margins, superior cosmetic results and high patient satisfaction, particularly in younger patients with early-stage breast cancer. This technique improves outcomes and reduces deformities. However, further research is required to evaluate its long-term oncologic safety and efficacy across diverse populations.