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Henry N, Sebag V, Safran T, Viezel-Mathieu A, Dionisopoulos T, Davison P, Vorstenbosch J. Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy. Ann Plast Surg 2024; 93:172-177. [PMID: 38775386 DOI: 10.1097/sap.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.
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Affiliation(s)
- Nader Henry
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Victoria Sebag
- McGill University, Faculty of Medicine, Montreal, Quebec, Canada
| | - Tyler Safran
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Viezel-Mathieu
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Tassos Dionisopoulos
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Peter Davison
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joshua Vorstenbosch
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Kuroda F, Urban CA, Dória M, Rabinovich Í, Spautz C, Lima R, Schunemann E, Furlan KA, Nissen L, Fornazari AC, Soares I, Sobreiro B, Lourenço M, Loureiro M. Three-dimensional Simulation on Patient-reported Outcomes Following Oncoplastic and Reconstructive Surgery of the Breast: A Randomized Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5804. [PMID: 38752215 PMCID: PMC11095956 DOI: 10.1097/gox.0000000000005804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/13/2024] [Indexed: 05/18/2024]
Abstract
Background Three-dimensional (3D) imaging using computer simulations is an evolving technology. There is a lack of strong data on the use of this technology for oncoplastic (OP) and reconstructive surgery. Methods A prospective, randomized, single-center trial including breast cancer patients undergoing OP or mastectomy with immediate breast reconstruction with implant (IBR) enrolled from November 2019 to October 2021 at the Hospital Nossa Senhora das Graças, Breast Unit in Curitiba, Brazil. Both patients undergoing OP and those in the IBR group were randomized to undergo 3D imaging and simulation of postoperative results (intervention group) or 3D imaging without simulation (control group). All patients were invited to complete a patient-reported outcome (BREAST-Q) expectations module and breast reconstruction or reduction/mastopexy module before and 6 months after surgery. Results A total of 96 patients were enrolled. Sixty-nine patients (45 OP and 24 IBR) completed the pre- and postoperative questionnaires and were randomized for the simulation. Women in the OP group had higher expectations for breast appearance when clothed than those in the IBR implant group (93.4 ± 16.3 versus 82.9 ± 26.5; P = 0.03). The intervention group was more satisfied with information than the control group (P = 0.021). Both patients who underwent OP and IBR believed that the 3D simulation helped them understand the surgical process (86.6% and 75%, respectively). Conclusions Preoperative 3D simulation significantly improved patient's satisfaction with information and did not decrease postoperative satisfaction with the outcomes. The incorporation of preoperative 3D simulation may be a valuable tool in breast reconstruction.
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Affiliation(s)
- Flávia Kuroda
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
- Post-graduation Program in Biotechnology, Universidade Positivo, Curitiba, Brazil
| | - Cícero A. Urban
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Maíra Dória
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Íris Rabinovich
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Cleverton Spautz
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Rubens Lima
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Eduardo Schunemann
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | - Karina Anselmi Furlan
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
- Post-graduation Program in Biotechnology, Universidade Positivo, Curitiba, Brazil
| | - Leonardo Nissen
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Isabela Soares
- From the Breast Unit, Hospital Nossa Senhora das Graças, Curitiba, Brazil
| | | | - Mateus Lourenço
- Department of Medicine, Evangélica Mackenzie University, Curitiba, Brazil
| | - Marcelo Loureiro
- Post-graduation Program in Biotechnology, Universidade Positivo, Curitiba, Brazil
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Hung YC, McCarthy JT, Park BC, Chaker SC, Saad M, Braun SA, Perdikis G, Higdon K. Comparison of Complication Rates Between Subpectoral vs Prepectoral Techniques in Prosthetic Breast Reconstruction. Aesthet Surg J 2023; 43:1285-1292. [PMID: 37184120 DOI: 10.1093/asj/sjad145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND The location of tissue expanders in implant-based breast reconstruction remains controversial due to variation in surgical techniques and devices. OBJECTIVES The aim of this study was to provide a comprehensive assessment of early and late complication rates between prepectoral and subpectoral placement of tissue expanders. METHODS A retrospective cohort study was conducted of all adult female patients who had undergone 2-stage implant-based breast reconstruction between 2013 and 2019 in our institution. Early complication was defined as complications that occurred within 30 days after surgery. Time-to-event analyses were performed and Cox proportional hazard models were used to adjust for confounders. RESULTS In total, 854 patients were included; 76% of patients underwent a subpectoral tissue expander placement. After the first-stage procedure, the early complication rate was 34% and the late complication rate was 36.4%. After the second-stage procedure, the early complication rate was 16.3% and the late complication rate was 16.1%. Location of the tissue expander did not predict either overall early or late complication rates, regardless of the stages of reconstruction, after adjusting for confounders. Tissue expanders placed in prepectoral plane were associated with a higher hazard ratio (HR) for developing early and late infection after the first stage of reconstruction (HR, 2.1 and 2.4, respectively) as well as late infection after the second stage of reconstruction (HR, 5.3; all P < .05). CONCLUSIONS Location of tissue expanders did not predict risk of complication. However, the prepectoral group was associated with an increased risk of developing infection. LEVEL OF EVIDENCE: 4
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Abdel-Razeq H. Surgical options for patients with early-stage breast cancer and pathogenic germline variants: an oncologist perspectives. Front Oncol 2023; 13:1265197. [PMID: 37781190 PMCID: PMC10539549 DOI: 10.3389/fonc.2023.1265197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Breast cancer continues to be the most common cancer diagnosed among women worldwide. Family history of breast cancer is frequently encountered, and 5-15% of patients may carry inherited pathogenic germline variants, identification of which can be helpful for both; patients themselves and their unaffected close relatives. The availability and affordability of molecular diagnostics, like next generation sequencing (NGS), had resulted in wider adoption of such technologies to detect pathogenic variants of cancer-predisposing genes. International guidelines had recently broadened the indications for germline genetic testing to include much more patients, and also expanded the testing to include multi-gene panels, while some professional societies are calling for universal testing of all newly diagnosed patients with breast cancer, regardless of their age, personal or family history. The risk of experiencing a contralateral breast cancer (CBC) or ipsilateral recurrence, is well known. Such risk is highest with variants like BRCA1 and BRCA2, but less well-studied with other less common variants. The optimal local therapy for women with BRCA-associated breast cancer remains controversial, but tends to be aggressive and may involve bilateral mastectomies, which may not have any survival advantage. Additionally, surgical management of unaffected women, known to carry a pathogenic cancer-predisposing gene, may vary from surveillance to bilateral mastectomies, too. The oncological safety, and the higher satisfaction of unaffected women and patients with new surgical techniques, like the skin-sparing (SSM) and nipple-sparing (NSM) mastectomies, eased up the process of counselling. In this review, we address the oncological safety of less aggressive surgical options for both; patients and unaffected carriers.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, The University of Jordan, Amman, Jordan
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Lu Wang M, Qin N, Chadab TM, Chen Y, Huang H, Ellison A, Otterburn DM. A Pilot Study Comparing Sensation in Buried Versus Nonburied Deep Inferior Epigastric Perforator Flaps. Ann Plast Surg 2023:00000637-990000000-00220. [PMID: 36921324 DOI: 10.1097/sap.0000000000003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
BACKGROUND Neurotized deep inferior epigastic perforator (DIEP) flaps have been shown to improve sensory recovery after mastectomy and reconstruction. With the recent trend toward nipple-sparing mastectomies, sensation likely originates within the buried DIEP flap and then innervates the breast skin. In contrast, for patients undergoing skin-sparing mastectomies, the DIEP flap skin is preserved, brought up to the surface, and directly innervated. In this study, we aim to evaluate inner breast region sensation between patients whose DIEP flap is buried and whose DIEP flap skin is brought to the surface. METHODS Seventy patients who underwent mastectomy with immediate reconstruction using the DIEP flap were prospectively identified. Of these, 60 patients underwent nipple-sparing mastectomy with buried DIEP flap reconstruction while 10 patients underwent skin-sparing mastectomy with nonburied DIEP flap reconstruction. Patients in both cohorts received nerve grafting using the 70 × 1-2-mm Avance Nerve Graft in identical fashion. Sensitivity evaluation was performed in five inner breast regions (corresponding to the nonburied DIEP flap area). RESULTS In the buried DIEP cohort, at 6 months postoperatively, there was a statistically significant difference in inner breast region sensitivity measurements compared with baseline levels (P < 0.001). In contrast, in the nonburied DIEP cohort, at 6 months postoperatively, sensation in the inner breast region was comparable with preoperative baseline levels (P = 0.236). At 24 months postoperatively, inner breast region sensitivity measurements in both cohorts were comparable with preoperative baseline measurements (P > 0.05). CONCLUSIONS Neurotized DIEP flap skin raised directly to the surface confers earlier sensory recovery than buried DIEP flaps. In patients who undergo skin-sparing mastectomies with nonburied DIEP flap reconstruction, they can expect significantly better sensation in the inner regions of the breast at 6 months postoperatively. In patients who undergo nipple-sparing mastectomies with buried DIEP flap reconstruction, they can expect sensation in the inner breast to return to preoperative baseline levels at a later time point-beginning as early as 24 months postoperatively.
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Affiliation(s)
- Marcos Lu Wang
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Nancy Qin
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | | | - Yunchan Chen
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - Hao Huang
- NewYork-Presbyterian Hospital, New York, NY
| | - Angela Ellison
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
| | - David M Otterburn
- From the Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine
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Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis. Breast J 2022; 2022:9654741. [PMID: 36474965 PMCID: PMC9701124 DOI: 10.1155/2022/9654741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/23/2022] [Accepted: 10/10/2022] [Indexed: 11/21/2022]
Abstract
Purpose As breast-conserving procedures become increasingly safe and viable options for surgical management of breast cancer, efforts have focused on assessing and optimizing patient-reported outcome measures (PROMs), such as nipple sensation. This study aims to evaluate the current understanding of nipple-areolar complex (NAC) sensation outcomes in breast cancer patients undergoing breast cancer surgeries, namely, nipple-sparing mastectomies (NSM), skin-sparing mastectomies (SSM), and lumpectomies. Methods Articles including terms related to "nipple," "mastectomy," "sensation," and "patient-reported outcome" were queried from three databases according to PRISMA guidelines. Study characteristics, patient demographics, and surgical details were recorded. Outcomes of interest included objective nipple sensitivity testing and PROMs. Results Of 888 manuscripts identified, 28 articles met the inclusion criteria. Twelve studies (n = 578 patients) used objective measures to evaluate sensitivity, such as monofilament testing. Sixteen studies (n = 1785 patients) assessed PROMs through validated or investigator-generated surveys. Three of the included studies reported NAC sensitivity in patients who received NSM with neurotization (n = 203 patients) through a variety of techniques that used various grafts to coapt a lateral intercostal nerve to the NAC nerve stumps. Results of investigator surveys showed that of 1565 patients without neurotization, nipple sensation was maintained in 29.0% (n = 453) of patients. Of 138 NSM patients without NAC neurotization, SWM testing showed an average loss of protective sensation in the nipple (average SWM score: 4.7) compared to normal or diminished sensation to light touch in nonoperated controls (average SWM score: 2.9, n = 195). Of patients who underwent NSM with neurotization, one study (n = 78) reported maintenance of NAC sensation in 100% of patients, while another study (n = 7) reported average diminished protective sensation in the nipple (average SWM score: 3.9). Conclusion Our study has shown that objective and patient-reported results of nipple sensitivity support nipple-sparing techniques as a viable option for preserving NAC sensation, although patients can expect a decrease in sensation overall. Neurotization of the NAC during NSM shows promising results of improved postoperative nipple sensitivity, though additional studies are warranted to confirm this finding. Variations between study methodologies highlight the lack of standardization in sensory testing techniques when evaluating NAC sensation.
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Sweitzer K, Carruthers K, Tiwari P, Kocak E. A Reliable Method for the Monitoring of Buried Free Flaps Using Near-Infrared Spectroscopy. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2022. [DOI: 10.1055/s-0042-1757321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background In recent years, there has been a shift toward nipple-sparing mastectomy (NSM) techniques which often negates the need for reconstruction with exposed cutaneous donor flap tissues. Although techniques for the monitoring of buried flaps have been proposed, none have been able to provide the benefits that come with cutaneous monitoring via near-infrared spectroscopy (NIRS). Therefore, we herein propose a novel method for monitoring deepithelialized flap tissues deep to the mastectomy flaps using NIRS technology.
Methods An NSM with free flap reconstruction was performed. The flap was designed with a skin island for placement of a cutaneous NIRS probe. Next, a silicone NIRS probe was placed on a deepithelialized portion of the flap under the mastectomy flap. The readings from this tunneled device were then compared to the control measurements obtained from the cutaneous NIRS monitor. This procedure was performed on three consecutive patients. The changes in StO2 recorded from both devices were compared using a paired, two-tailed Student's t-test.
Results During flap monitoring, there were no issues with probe dislodgement and signal quality averaged greater than 90. Furthermore, probe removal was easily accomplished at bedside. There was no harm to the mastectomy skin flaps by affixing the probe and the pocket which contained the probe quickly closed down after removal. Using the Student's t-test, a p-value of 0.995 was calculated indicating no statistically significant difference between the StO2 readings from the cutaneous and the tunneled probes.
Conclusion By using this novel method, NIRS technology can reliably be applied to the monitoring of buried free flap tissues. The proposed technique could be applied to a variety of flaps beyond the realm of breast reconstruction and may prove to be particularly useful in the setting of head and neck reconstruction. The results of this study suggest that high quality postoperative flap monitoring is possible without compromising the aesthetic result.
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Affiliation(s)
- Keith Sweitzer
- Division of Plastic Surgery, Strong Memorial Hospital, University of Rochester, Rochester, New York
| | - Katherine Carruthers
- Division of Plastic and Reconstructive Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | | | - Ergun Kocak
- Midwest Breast & Aesthetic Surgery, Gahanna, Ohio
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Li S, Zhao Y, Yan L, Yang Z, Qiu P, Chen H, Zhou Y, Niu L, Yan Y, Zhang W, Zhang H, He J, Zhou C. Effect of the Nipple-Excising Breast-Conserving Therapy in Female Breast Cancer: A Competing Risk Analysis and Propensity Score Matching Analysis of Results Based on the SEER Database. Front Oncol 2022; 12:848187. [PMID: 35494069 PMCID: PMC9048049 DOI: 10.3389/fonc.2022.848187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/16/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Due to the lack of randomized controlled trial, the effectiveness and oncological safety of nipple-excising breast-conserving therapy (NE-BCT) for female breast cancer (FBC) remains unclear. We aimed to explore and investigate the prognostic value of NE-BCT versus nipple-sparing breast-conserving therapy (NS-BCT) for patients with early FBC. Methods In this cohort study, data between NE-BCT and NS-BCT groups of 276,661 patients diagnosed with tumor–node–metastasis (TNM) stage 0–III FBC from 1998 to 2015 were retrieved from the Surveillance, Epidemiology, and End Results database. Propensity score matching analysis, Kaplan–Meier, X-tile, Cox proportional hazards model, and competing risk model were performed to evaluate the effectiveness and oncological safety for patients in NE-BCT and NS-BCT groups. Results A total of 1,731 (0.63%) patients received NE-BCT (NE-BCT group) and 274,930 (99.37%) patients received NS-BCT (NS-BCT group); 44,070 subjects died after a median follow-up time of 77 months (ranging from 1 to 227 months). In the propensity score matching (PSM) cohort, NE-BCT was found to be an adversely independent prognostic factor affecting overall survival (OS) [hazard ratio (HR), 1.24; 95% CI, 1.06–1.45, p=0.0078]. Subjects in NE-BCT group had similar breast-cancer-specific survival (BCSS) (HR, 1.15; 95%CI, 0.88–1.52, p=0.30) and worse other-causes-specific death (OCSD) (HR, 1.217; 95%CI, 1.002–1.478, p=0.048<0.05) in comparison with those in the NS-BCT group. Conclusions Our study demonstrated that the administration of NE-BCT is oncologically safe and reliable and can be widely recommended in clinics for women with non-metastatic breast cancer.
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Affiliation(s)
- Shouyu Li
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yuting Zhao
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Lutong Yan
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Zejian Yang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Pei Qiu
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Heyan Chen
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yudong Zhou
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Ligang Niu
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yu Yan
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Wei Zhang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Huimin Zhang
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jianjun He
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Jianjun He, ; Can Zhou,
| | - Can Zhou
- Department of Breast Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Jianjun He, ; Can Zhou,
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Patzelt M, Zarubova L, Vecerova M, Barta J, Ouzky M, Sukop A. Risk Comparison Using Autologous Dermal Flap and Absorbable Breast Mesh on Patient Undergoing Subcutaneous Mastectomy with Immediate Breast Reconstruction. Aesthetic Plast Surg 2022; 46:1145-1152. [PMID: 35165758 DOI: 10.1007/s00266-022-02799-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/17/2022] [Indexed: 11/01/2022]
Abstract
In patients with large breasts undergoing a subcutaneous mastectomy with immediate implant-based reconstruction, is necessary to perform a mastopexy. The combination of these procedures increases the complication rate. To reduce it, it is necessary to cover the lower pole of the implant. Our study aimed to compare the use of an autologous dermal flap and an absorbable breast mesh. A total of 64 patients without previous breast surgery were divided into 2 groups, each with 32 patients. In the 1st group, the implant was covered with an autologous caudally based dermal flap, sutured to the great pectoral muscle. In the 2nd group, the implant was covered with a fully absorbable breast mesh, fixed caudally in the inframammary fold and cranially to the great pectoral muscle. The incidence of complications, the aesthetic effect, and patient satisfaction were evaluated in a one-year follow-up. In the 1st group, there were 2 cases of seroma, 2 partial nipple-areola complex necrosis, 4 cases of dehiscence in the T-suture, and the malposition of the implant in 2 patients. In the 2nd group, there were 2 cases of seroma, 2 cases of T-junction dehiscence, and 1 case of full nipple-areola complex necrosis, which resulted in implant loss. There was no significant difference in patient satisfaction between the study groups. The dermal flap is more suitable for breasts with pronounced ptosis. The use of the synthetic mesh is suitable for smaller breasts, where the possible dermal flap would be too small to cover the implant. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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10
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Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction. Breast J 2022; 2022:7339856. [PMID: 35711891 PMCID: PMC9187267 DOI: 10.1155/2022/7339856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/15/2022] [Indexed: 11/18/2022]
Abstract
Background Immediate breast reconstruction following nipple-sparing mastectomy (NSM) is widely used for its cosmetic benefits. Due to the lack of guidelines, the types of incisions in NSM vary and which method is superior remains a debate. In this study, we hypothesized that the periareolar incision has a higher risk of complications, such as nipple-areolar complex (NAC) necrosis, than other incisions. Methods A retrospective chart review was conducted and divided into three groups: the periareolar, radial, and lateral incision groups. The reconstruction method and complications of NAC necrosis, wound dehiscence, seroma, hematoma, infection, and reconstruction failure were investigated. Results A total of 103 patients (periareolar incision (33%, n = 34), radial incision (39.8%, n = 41), and lateral incision (27.2%, n = 28)) who underwent NSM and immediate breast reconstruction from 2018 to 2020 were included. The reconstruction methods were direct-to-implant, DIEP flap, LD flap, and PAP flap, and there was all of which had no statistically significant difference between the groups regarding the reconstruction method (p=0.257). In terms of complications, there was no significant difference in NAC necrosis (29.4%, 19.5%, and 21.4%, in the periareolar, radial, and lateral groups, respectively; p=0.578), wound dehiscence, seroma or hematoma, infection, and reconstruction failure. Conclusion Breast reconstruction following NSM through periareolar incision does not increase the incidence of complications, including NAC necrosis. However, since only Asian patients with low BMI were included, if an appropriate patient group is selected for immediate reconstruction after NSM, reconstruction can be safely performed through the periareolar incision, and good cosmetic results can be obtained.
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11
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Oles N, Darrach H, Landford W, Garza M, Twose C, Park CS, Tran P, Schechter LS, Lau B, Coon D. Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 1: Breast/Chest, Face, and Voice). Ann Surg 2022; 275:e52-e66. [PMID: 33443903 DOI: 10.1097/sla.0000000000004728] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. METHODS A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to assess currently reported complication, satisfaction, and other outcome rates. RESULTS Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. CONCLUSIONS This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have assembled a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to high-quality research where improvement efforts should be focused.
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Affiliation(s)
- Norah Oles
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Halley Darrach
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Wilmina Landford
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Matthew Garza
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Claire Twose
- Welch Medical Library, Johns Hopkins University, Baltimore, Maryland
| | - Chanjun S Park
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Phuong Tran
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Brandyn Lau
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Devin Coon
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
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12
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Pestana IA, Jones VM, Velazquez C. Breast Reconstruction and Nipple-Sparing Mastectomy: Technical Modifications and Their Outcomes Over Time at an Academic Breast Center. Ann Plast Surg 2021; 86:S521-S525. [PMID: 34100809 DOI: 10.1097/sap.0000000000002701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Superior aesthetic outcomes can be achieved with mastectomy techniques that maximize breast envelope preservation and maintain the nipple-areolar complex. This is the impetus for the popularization of the nipple-sparing mastectomy (NSM). Nipple-sparing mastectomy is a challenging procedure due to potential ischemia of the mastectomy flap (which includes the nipple-areolar complex) and the risk of incomplete oncologic resection. We review our experience with NSM, identify technique modifications used over time, and evaluate reconstructive outcomes of NSM and its modifications. METHODS A retrospective review of consecutive patients with NSM and breast reconstruction over an 8-year period was completed. RESULTS Fifty-five patients underwent 95 NSMs. Indications included invasive and in situ cancer, atypical ductal hyperplasia, and risk reduction. In the first 4 years of experience, the most frequently used NSM incision was radial (lateral) whereas use of a variety of incision patterns was noted in the second 4 years. Overall NSM and breast reconstruction complication rate for the entire study period was 50.9% and included a full-thickness mastectomy skin flap necrosis/nipple necrosis rate of 8.4%. In situ cancer of the nipple was identified in 3.2% of the patients, and 1 patient had locoregional recurrence. Overall complication rate was lower in the second 4 years of experience with NSM and reconstruction. One third of the patients underwent intraoperative fluorescent angiography (FA) to assess mastectomy skin perfusion before reconstruction start. Of the patients who had FA due to perfusion concerns, more than 70% of studies demonstrated poor perfusion and 83.3% of these patients had reconstruction delayed based on these results. Immediate, implant-based reconstruction was performed most commonly. An average of 2.66 procedures were required to achieve reconstruction completion, and 92.4% of the patients who sought reconstruction achieved completion. CONCLUSIONS At our institution, NSM use is increasing, NSM incision pattern types used are expanding, and complication rates are decreasing. Immediate, implant-based reconstruction is most commonly used in combination with NSM at our institution. Fluorescent angiography is used to assess mastectomy skin perfusion and likely limits mastectomy complication effects on reconstruction. Despite the occurrence of complications, most patients will complete the breast reconstruction process.
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Affiliation(s)
- Ivo A Pestana
- From the Departments of Plastic & Reconstructive Surgery
| | - V Morgan Jones
- General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
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Kooijman MML, Hage JJ, Oldenburg HSA, Stouthard JM, Woerdeman LAE. Surgical Complications of Skin-Sparing Mastectomy and Immediate Implant-Based Breast Reconstruction in Women Concurrently Treated With Adjuvant Chemotherapy for Breast Cancer. Ann Plast Surg 2021; 86:146-150. [PMID: 32568758 DOI: 10.1097/sap.0000000000002435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM To date, studies on adjuvant chemotherapy as a risk factor for the surgical outcome of combined mastectomy and breast reconstruction were hampered by the inclusion of mixed reconstructive cohorts of both delayed and immediate timing and of both autologous and implant-based techniques. Consequently, there is a paucity of data on the impact of adjuvant chemotherapy on surgical complication rates after combined skin-sparing mastectomy and immediate implant-based breast reconstruction. METHODOLOGY We compared the postoperative complications that occurred within 16 weeks after this combined procedure in 131 women (139 breasts) treated with adjuvant chemotherapy with those in a control group of 491 women (517 breasts) not receiving any adjuvant therapy within 16 weeks. RESULTS In line with the clinically indicated selection of women to undergo adjuvant chemotherapy, the interventional group differed significantly from the control group in 7 of the 12 patient- and procedure-related characteristics. The prevalence of minor complications (13.7% and 12.4%, respectively, P = 0.68) and major complications (31.7% and 29.4%, respectively, P = 0.60) did not differ significantly between the interventional group and the controls. The fraction of breasts that needed unscheduled surgery (0.29 and 0.24, respectively, P = 0.20), the fraction of total number of interventions (0.34 and 0.33, respectively, P = 0.24), and the fraction of implants lost (0.72 and 0.67, respectively, P = 0.86) did not differ significantly between both groups. The onset of chemotherapy, furthermore, seemed not to influence the occurrence or severity of complications. CONCLUSIONS Like other women who have to undergo mastectomy, women who need to undergo adjuvant chemotherapy can potentially benefit from combined skin-sparing mastectomy and immediate implant-based breast reconstruction.
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Affiliation(s)
| | - J Joris Hage
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Jacqueline M Stouthard
- Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
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14
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Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple‐sparing mastectomy. J Surg Oncol 2020; 122:29-35. [DOI: 10.1002/jso.25909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Kopkash
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Mark Sisco
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Elizabeth Poli
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | - Akhil Seth
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Catherine Pesce
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
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15
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Skin-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction With Submuscular-Dermal-Mesh Pocket. Ann Plast Surg 2020; 82:19-27. [PMID: 30247191 DOI: 10.1097/sap.0000000000001614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite skin-sparing mastectomy techniques have significantly improved reconstructive options and aesthetic outcomes, patients with large and ptotic breasts remain a challenging group to treat satisfactorily. The Wise-pattern skin-reducing mastectomy (SRM) has been designed for this kind of patients but is not without morbidity. To improve safety, the authors reviewed their experience with a modified SRM and immediate 1-stage implant-based breast reconstruction, using a synthetic absorbable mesh combined with a dermal flap. METHODS A retrospective review was undertaken to identify women with medium to large ptotic breast and medium minimally ptotic breast who had undergone SRM and direct-to-implant breast reconstruction using definitive anatomical gel implant, de-epithelialized dermal flap, and absorbable synthetic mesh, between October 2014 and December 2016. Patient demographics were queried, and complication rates, aesthetic outcomes, and patients satisfaction were assessed. RESULTS Sixty-two procedures of SRM were performed in 56 patients. Forty-five women received contralateral symmetrization. Twenty-one overall complications occurred in 16 patients. Statistical correlation between risk factors and complications onset was assessed. Body mass index resulted the most substantial risk factor (P = 0.0028) for developing complications, whereas preoperative chemotherapy (P = 0.0050) and comorbidities (P = 0.0117) played a decent role. Smoking attitude (P = 0.1122), age (P = 0.9990), and implant weight (P = 0.1583) did not result as significant risk factors. The reconstructive outcomes were good to excellent in 92.8%, with patient satisfaction ranking very to highly satisfied in 84%. CONCLUSIONS The authors' series suggests that SRM with direct-to-implant breast reconstruction can be easily performed when an appropriate SRM pattern is designed, providing complete implant coverage with submuscular-dermal-mesh pocket.
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Papassotiropoulos B, Güth U, Chiesa F, Rageth C, Amann E, Baege A, Elfgen C, Varga Z, Moskovszky L, Endhardt K, Masser R, Tinguely M, Farhadi J, Lardi A, Dammann F, Diebold J, Li Q, Dubsky P, Tausch C. Prospective Evaluation of Residual Breast Tissue After Skin- or Nipple-Sparing Mastectomy: Results of the SKINI-Trial. Ann Surg Oncol 2019; 26:1254-1262. [PMID: 30830538 DOI: 10.1245/s10434-019-07259-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study was designed to investigate the presence of residual breast tissue (RBT) after skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) and to analyse patient- and therapy-related factors associated with RBT. Skin-sparing mastectomy and NSM are increasingly used surgical procedures. Prospective data on the completeness of breast tissue resection is lacking. However, such data are crucial for assessing oncologic safety of risk-reducing and curative mastectomies. METHODS Between April 2016 and August 2017, 99 SSM and 61 NSM were performed according to the SKINI-trial protocol, under either curative (n = 109) or risk-reducing (n = 51) indication. After breast removal, biopsies from the skin envelope (10 biopsies per SSM, 14 biopsies per NSM) were taken in predefined radial localizations and assessed histologically for the presence of RBT and of residual disease. RESULTS Residual breast tissue was detected in 82 (51.3%) mastectomies. The median RBT percentage per breast was 7.1%. Of all factors considered, only type of surgery (40.4% for SSM vs. 68.9% for NSM; P < 0.001) and surgeon (P < 0.001) were significantly associated with RBT. None of the remaining factors, e.g., skin flap necrosis, was associated significantly with RBT. Residual disease was detected in three biopsies. CONCLUSIONS Residual breast tissue is commonly observed after SSM and NSM. In contrast, invasive or in situ carcinomas are rarely found in the skin envelope. Radicality of mastectomy in this trial is not associated with increased incidence of skin flap necrosis. ClinicalTrials.gov Identifier NCT03470909.
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Affiliation(s)
| | - Uwe Güth
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Federica Chiesa
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Christoph Rageth
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Esther Amann
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Astrid Baege
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Constanze Elfgen
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Linda Moskovszky
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Katharina Endhardt
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Jian Farhadi
- Department of Plastic Surgery, Brust-Zentrum, Zurich, Switzerland
| | - Alessia Lardi
- Department of Plastic Surgery, Brust-Zentrum, Zurich, Switzerland
| | | | | | - Qiyu Li
- Statistician Unit, Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St. Anna, Lucerne, Switzerland.,Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Tausch
- Department of Breast Surgery, Brust-Zentrum, Zurich, Switzerland
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Galimberti V, Morigi C, Bagnardi V, Corso G, Vicini E, Fontana SKR, Naninato P, Ratini S, Magnoni F, Toesca A, Kouloura A, Rietjens M, De Lorenzi F, Vingiani A, Veronesi P. Oncological Outcomes of Nipple-Sparing Mastectomy: A Single-Center Experience of 1989 Patients. Ann Surg Oncol 2018; 25:3849-3857. [PMID: 30225833 DOI: 10.1245/s10434-018-6759-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is increasingly used in women with breast cancer who are not eligible for conservative surgery, but extensive outcome data are lacking and indications have not been established. OBJECTIVE The aim of this study was to assess the oncological outcomes of NSM in a large series of patients with invasive or in situ breast cancer treated at a single center. METHODS We analyzed 1989 consecutive women who had an NSM in 2003-2011, for invasive (1711 patients) or in situ cancer (278 patients) at the European Institute of Oncology, Italy, and followed-up to December 2016. Endpoints were local recurrences, recurrences in the nipple-areola complex (NAC), NAC necrosis, and overall survival (OS). RESULTS After a median follow-up of 94 months (interquartile range 70-117), 91/1711 (5.3%) patients with invasive cancer had local recurrence (4.8% invasive disease, 0.5% in situ disease), and 11/278 (4.0%) patients with in situ disease had local recurrence (1.8% invasive disease, 2.2% in situ disease). Thirty-six (1.8%) patients had NAC recurrence, 9 with in situ disease (4 invasive and 5 in situ recurrences), and 27 with invasive disease (18 invasive and 9 in situ recurrences). NAC loss for necrosis occurred in 66 (3.3%) patients. There were 131 (6.6%) deaths, 109 (5.5%) as a result of breast cancer. OS at 5 years was 96.1% in women with invasive cancer and 99.2% in women with in situ disease. CONCLUSIONS The findings in this large series, with a median follow-up of nearly 8 years, indicate that NSM is oncologically safe for selected patients. The rate of NAC loss was acceptably low.
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Affiliation(s)
- Viviana Galimberti
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy.
| | - Consuelo Morigi
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Giovanni Corso
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Elisa Vicini
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Sabrina Kahler Ribeiro Fontana
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy.,Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Paola Naninato
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Silvia Ratini
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Francesca Magnoni
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Antonio Toesca
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Andriana Kouloura
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy
| | - Mario Rietjens
- Division of Plastic and Reconstructive Surgery, IRCCS European Institute of Oncology, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic and Reconstructive Surgery, IRCCS European Institute of Oncology, Milan, Italy
| | - Andrea Vingiani
- Department of Pathology, IRCCS European Institute of Oncology, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, IRCCS European Institute of Oncology, Milan, Italy.,University of Milan School of Medicine, Milan, Italy
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Miyake R, Kinoshita S, Shimada N, Uchida K, Takeyama H, Morikawa T. Preservation of the nipple-areola complex in skin-sparing mastectomy for early breast cancer. Surg Today 2018; 48:591-597. [PMID: 29468434 DOI: 10.1007/s00595-018-1633-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/05/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Skin-sparing mastectomy (SSM) enables a radical cure of breast cancer while overcoming the cosmetic issues related to surgery. We review our experience of performing SSMs and assess whether preservation of the nipple-areola complex (NAC) could have been an option for some patients who underwent SSM. METHODS The subjects of this retrospective study were women who underwent SSM that utilized four incision types; namely, the so-called tennis racket incision, a periareolar and midaxillary incision, an areola-sparing and midaxillary incision, and a small transverse elliptical incision. We assessed whether preservation of the NAC would have been an option in SSM, based on histologic examination of three serial cut surfaces of the specimen around the nipple, ruling out the option when evidence of the malignant lesion/s was found in at least one of the following locations: in the nipple, within a 1-cm radius from the base of the nipple, or within 1 cm from the surface of the NAC. RESULTS We performed 193 SSMs. The cumulative 10-year local disease-free survival rate was 98%, with 89% of patients reporting levels of satisfaction with the reconstructed breast, of excellent, very good, or good. We evaluated that 70 of the 193 procedures could have been performed as nipple-sparing mastectomy (NSM). CONCLUSIONS The outcomes of SSM in this series were excellent and NSM might have been an option for about one-third of the patients.
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Affiliation(s)
- Ryo Miyake
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Satoki Kinoshita
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Naoko Shimada
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ken Uchida
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Takeyama
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toshiaki Morikawa
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Heidemann LN, Gunnarsson GL, Salzberg CA, Sørensen JA, Thomsen JB. Complications following Nipple-Sparing Mastectomy and Immediate Acellular Dermal Matrix Implant-based Breast Reconstruction-A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1625. [PMID: 29464161 PMCID: PMC5811291 DOI: 10.1097/gox.0000000000001625] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acellular dermal matrix was introduced in breast reconstruction in 2001 and is gradually becoming a standard component for immediate breast reconstruction and nipple-sparing mastectomy. The reconstructive technique allows for improved aesthetic outcomes. However, there seems to be uncertainty regarding complication rates. The aim of this review was to systematically evaluate complication rates related to this method. METHODS This systematic review was conducted according to the recommendations outlined in the Cochrane Handbook for reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Relevant databases were searched for in the literature concerning the use of acellular dermal matrix in implant-based nipple-sparing mastectomy and immediate breast reconstruction. All studies underwent detailed quality assessment. Summarized outcome rates were computed using meta-analysis. RESULTS Nine of 1,039 studies were eligible for inclusion yielding 778 procedures. The quality was acceptable for all included studies. The meta-analysis found the rate of skin necrosis to be 11%, nipple necrosis 5%, infection in 12%, hematoma in 1%, treated seroma in 5%, explantation 4%, and unplanned return to the operating room in 9%. CONCLUSION The use of acellular dermal matrix in nipple-sparing mastectomy and implant-based breast reconstruction can be done with acceptable complication rates in selected patients. We recommend future studies to include specific definitions when reporting complication rates. Furthermore, future studies should elaborate on demographic characteristics of the included study samples and include predictor analysis to enhance knowledge of high risk patients.
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Affiliation(s)
- Lene Nyhøj Heidemann
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Gudjon L. Gunnarsson
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - C. Andrew Salzberg
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Jens Ahm Sørensen
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Jørn Bo Thomsen
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
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Galimberti V, Vicini E, Corso G, Morigi C, Fontana S, Sacchini V, Veronesi P. Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications. Breast 2017; 34 Suppl 1:S82-S84. [PMID: 28673535 DOI: 10.1016/j.breast.2017.06.034] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies are relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0-3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment. Indications are carcinoma or DCIS that require mastectomy (including after neoadjuvant chemotherapy). NSM is also suitable for women undergoing risk-reducing bilateral mastectomy. Tumor not less than 2 cm from the NAC is recommended, but may be less important than no evidence of nipple involvement on mandatory intraoperative nipple margin assessment. A positive margin is an absolute contraindication for nipple preservation. Other contraindications are microcalcifications close to the subareolar region and a positive nipple discharge. Complication rates are similar to those for other types of post-mastectomy reconstructions. The main complication of NSM is NAC necrosis, however as surgeon experience matures, frequency declines. Factors associated with complications are voluminous breast, ptosis, smoking, obesity, and radiotherapy. Since the access incision is small, breast tissue may be left behind, so only experienced breast surgeons should do these operations in close collaboration with the plastic surgeon. For breast cancer patients requiring mastectomy, NSM should be the option of choice.
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Affiliation(s)
| | - Elisa Vicini
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - Giovanni Corso
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - Consuelo Morigi
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - Sabrina Fontana
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - Virgilio Sacchini
- Division of Senology, European Institute of Oncology, Milan, Italy; University of Milan, Milan, Italy
| | - Paolo Veronesi
- Division of Senology, European Institute of Oncology, Milan, Italy; University of Milan, Milan, Italy
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21
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The impact of the Biomolecular Era on breast cancer surgery. Surgeon 2017; 15:169-181. [DOI: 10.1016/j.surge.2016.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/14/2016] [Accepted: 09/18/2016] [Indexed: 01/10/2023]
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22
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Echazarreta-Gallego E, Pola-Bandrés G, Arribas-Del Amo MD, Gil-Romea I, Sousa-Domínguez R, Güemes-Sánchez A. Treatment of Implant Exposure due to Skin Necroses after Skin Sparing Mastectomy: Initial Experiences Using a Not Selective Random Epigastric Flap. World J Surg 2017; 41:2559-2565. [PMID: 28466362 DOI: 10.1007/s00268-017-4041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Breast prostheses exposure is probably the most devastating complication after a skin sparing mastectomy (SSM) and implant-based, one-stage, breast reconstruction. This complication may occur in the immediate post-operative period or in the weeks and even months after the procedure. In most cases, the cause is poor skin coverage of the implant due to skin necrosis. PATIENTS AND METHODS Eight consecutive cases of implant exposure (or risk of exposure) due to skin necrosis in SSM patients over a period of 5 years, all patients were treated using a random epigastric rotation flap, executed by the same medical team. RESULTS A random epigastric flap (island or conventional rotation flap) was used to cover the skin defect. All the patients completed the procedure and all prostheses were saved; there were no cases of flap necrosis or infection. CONCLUSIONS Cases of skin necrosis after SSM and immediate implant reconstruction, in which the implant is at risk of exposure, can be successfully treated with a random epigastric rotation flap.
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Affiliation(s)
- Estíbaliz Echazarreta-Gallego
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain.
| | - Guillermo Pola-Bandrés
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain
| | - María Dolores Arribas-Del Amo
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain
| | - Ismael Gil-Romea
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain
| | - Ramón Sousa-Domínguez
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain
| | - Antonio Güemes-Sánchez
- Breast Unit. Department of Surgery, Hospital Clínico Universitario de Zaragoza, Avenida San Juan Bosco 15, 50005, Saragossa, Spain
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Donovan CA, Harit AP, Chung A, Bao J, Giuliano AE, Amersi F. Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter? Ann Surg Oncol 2016; 23:3226-3231. [DOI: 10.1245/s10434-016-5323-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Sisco M, Kyrillos AM, Lapin BR, Wang CE, Yao KA. Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States. Breast Cancer Res Treat 2016; 160:111-120. [PMID: 27620883 DOI: 10.1007/s10549-016-3975-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/06/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE For many women, nipple-sparing mastectomy (NSM) provides aesthetic and quality-of-life outcomes superior to skin-sparing mastectomy. Accumulating data suggest that NSM provides similar oncologic outcomes in select breast cancer patients. This study sought to determine national trends in NSM use. METHODS Using the National Cancer Data Base, 6254 women with breast cancer who underwent NSM between 2010 and 2013 were identified. NSM rates were determined relative to the number of patients who received a mastectomy with reconstruction (n = 114,849). Associations between patient, tumor, and facility characteristics and NSM were assessed using logistic regression. RESULTS The rate of NSM increased from 2.9 to 8.0 % between 2010 and 2013. NSM was most commonly performed in academic (adjusted odds ratio [OR] 1.43, p < 0.001) and high-volume (OR 1.59, p < 0.001) breast centers. There was up to a 5.8-fold variation in its delivery between geographic census regions (p < 0.001). Of 1231 hospitals, only 491 (39.9 %) reported performing at least one NSM during the study period. Half of all NSMs were performed by the top 6 % (n = 30) of NSM-performing centers. NSM was associated with small tumor size (p < 0.001), lower tumor grades (p < 0.05), and negative nodal status (p < 0.001). However, half of NSM patients had at least one tumor characteristic that diverged from current (2016) NCCN recommendations for the procedure. CONCLUSIONS The use of therapeutic NSM is increasing dramatically in the United States, despite recommendations that the procedure be used with caution. As NSM becomes increasingly common, efforts are needed to monitor its long-term oncologic outcomes and to ensure equitable access to it.
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Affiliation(s)
- Mark Sisco
- Division of Plastic Surgery, NorthShore University HealthSystem, Northbrook, IL, 60062, USA.
| | - Alexandra M Kyrillos
- Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, 60201, USA
| | - Brittany R Lapin
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, 60201, USA
| | - Chihsiung E Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, 60201, USA
| | - Katharine A Yao
- Division of Surgical Oncology, NorthShore University HealthSystem, Evanston, IL, 60201, USA
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