Contemporary controversies in breast cancer surgery: minimally invasive mastectomy, oncologic de-escalation after neoadjuvant therapy, and the evolving role of oncoplastic surgery: A narrative review of the Breast and Reconstructive Plastic Surgery session at the 44th ACOI National Congress, 2026

Background: Breast cancer surgery is evolving toward individualized strategies, balancing oncological safety, functional preservation, aesthetics, and quality of life. Contemporary decision-making increasingly integrates tumor biology, response to systemic therapy, multidisciplinary assessment, and patient preferences. Key areas include minimally invasive mastectomy, surgical de-escalation after neoadjuvant systemic therapy, and oncoplastic breast surgery. Methods: This narrative review derives from the Breast and Reconstructive Plastic Surgery session of the 44th ACOI National Congress (Palermo, Italy, 24–27 May 2026), structured as a thesis–antithesis–synthesis debate. The complete session transcript was used to reconstruct the principal themes and expert discussions according to the methodology described by Molteni et al. Current peer-reviewed evidence and international guidelines were integrated to contextualize the discussion. Electronic presentations and individual clinical cases were not considered primary evidence. Results: Minimally invasive mastectomy may improve cosmetic outcomes and patient satisfaction in selected patients but remains limited by operative time, costs, and regulatory considerations. After neoadjuvant therapy, breast-conserving surgery remains underused despite increasing tumor downstaging, while axillary management is shifting from routine dissection toward sentinel lymph node biopsy and targeted axillary surgery. Residual disease distribution remains critical for surgical planning despite the prognostic relevance of pathological complete response. Oncoplastic surgery has become integral to multidisciplinary breast cancer care, highlighting the need for appropriate training, credentialing, quality assurance, and organizational models. Conclusions: Innovation should remain guided by oncological appropriateness, individualized patient selection, multidisciplinary decision-making, and patient-centered outcomes, with technology enhancing rather than replacing sound clinical judgment.