Breast cancer is the most common cancer in women worldwide [
7]. Breasts are not only functional feeding organs for infants, but are also cosmetically important for women, and breasts should be preserved if possible. Compared with mastectomy, BCS provides better cosmetic and psychosocial outcomes [
4]. Because patients treated with BCS or mastectomy followed by radiotherapy have similar outcomes, BCS has been opted as a standard surgical strategy [
2,
3]. Successful BCS involves excising complete tumor and tumor margin, together with preserving the normal shape and normal tissue of the breast as much as possible. However, despite adequate resection, a positive margin is often found. Previous reports suggest 15%–47% margin positivity in BCS [
8]. Therefore, to circumvent this issue, the lesion including adjacent normal tissue should be completely excised at the time of BCS, although this affects the cosmetic outcome. If the size of the tumor is relatively large than the breast, unwanted deformity and asymmetry may occur after BCS, leading to poor psychosocial outcomes in the patients [
9,
10]. Several methods of oncoplastic surgery, such as breast glandular tissue reposition, superior pedicle mammoplasty, racquet mammoplasty, and J-mammoplasty, have been performed to reduce the deformity and asymmetry of the breast [
11]. However, these procedures can leave longer incisions and multiple scars during surgery [
11]. In most cases of BCS, an incision is made on the skin directly above the tumor, where the incision scar sticks to the surgical site and scarring often occurs due to inversion. Moreover, if the incision is in a prominent area, it hampers the social activity, reducing quality of life and affecting prognosis in patients [
12]. However, to hide the scars, an incision is made on the periareolar region, axilla, or inframammary folds [
6]. Further, endoscopic BCS has been conducted to address these problems and several studies on its usefulness have been reported [
13]. If the tumor is large or located far from the nipple, complete removal of the tumor is often challenging in the periareolar approach due to a narrow field of view. When the length of the incision is insufficient, a zigzag incision is commonly used, and because the tension is dispersed, organ undergoes less scarring than due to linear incisions, and the P-Z incision can be used in augmentation mammoplasties [
14]. Gryskiewicz JM, Hatfield AS have reported that a P-Z incision could reduce the complications in terms of cosmetic aspects, such as delay in healing, hypertrophic scars, and pigmentation alterations [
15]. In our study, most of the patients showed good cosmetic outcomes several months after surgery (
Figure 2). Carvajal and Echeverry et al. have reported the successful insertion of breast implants using a semicircular P-Z incision technique in women with an areolar diameter of less than 3 cm. In patients with small areolae or large tumors, the donut mastopexy (round block) resection technique is helpful, and in our study, the P-Z incision enabled tumor removal without any problems [
16].
However, our study has a few limitations. First, it was retrospective and conducted in a single institution. Second, outcome was not compared with patients that underwent BCS with other incision techniques. Third, cosmetic aspects were not evaluated using questionnaires addressing patient satisfaction. However, the tumor-free resection margin rate, surgery duration, and postoperative complications were similar to those in previous studies. Moreover, the cosmetic outcomes were better than those of other incision techniques.
The use of the P-Z incision technique in BCS ensures that sufficient operative field is obtained, so that larger tumors or tumors distant from the nipple can be removed relatively easily. Additionally, scarring can be reduced with good cosmetic outcomes.