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Webster AJ, Shanno JN, Santa Cruz HS, Kelly BN, Garstka M, Henriquez A, Specht MC, Gadd MA, Verdial FC, Nguyen A, Oseni TO, Coopey SB, Smith BL. Oncologic Safety of Nipple-Sparing Mastectomy for Breast Cancer in BRCA Gene Mutation Carriers: Outcomes at 70 Months Median Follow-Up. Ann Surg Oncol 2023; 30:3215-3222. [PMID: 36604360 DOI: 10.1245/s10434-022-13006-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/04/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Retention of the nipple-areola complex with nipple-sparing mastectomy (NSM) techniques provides a more natural cosmetic result than procedures that sacrifice the nipple. While the oncologic safety of NSM is established by several studies, there is little long-term data on outcomes in BRCA mutation carriers with breast cancer. PATIENTS AND METHODS BRCA1/2 mutation carriers who underwent NSM and immediate reconstruction from 2008 to 2019 were reviewed and patients with breast cancer on biopsy or final pathology were included. Patient demographics and tumor characteristics, as well as treatment, recurrence, and survival data were collected. RESULTS A total of 114 therapeutic NSM were performed in 105 BRCA mutation carriers (56 BRCA1, 47 BRCA2, and two women with both mutations). Median age was 45 years. Cancers were 18% stage 0, 52% stage I, 27% stage II, and 3% stage III. Mean invasive tumor size was 1.6 cm and 33 (35%) invasive tumors were triple negative. There were five (4.4%) positive nipple margins on final pathology; all underwent nipple excision. Most patients (80, 76%) received systemic therapy: 65 (62%) received chemotherapy and 48 (46%) received endocrine therapy. At 70 months median follow-up (range 15-150 months), no patient had developed a recurrence in the retained nipple-areola complex or at the site of a nipple excised for a positive margin. The rate of locoregional recurrence outside the nipple was 2.6%, and the rate of distant recurrence was 3.8%. Overall survival was 96%. CONCLUSIONS NSM is a safe option for BRCA1 and BRCA2 mutation carriers who undergo mastectomy for breast cancer.
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Affiliation(s)
- Alexandra J Webster
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Julia N Shanno
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi S Santa Cruz
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bridget N Kelly
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan Garstka
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anthony Henriquez
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Francys C Verdial
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Anvy Nguyen
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tawakalitu O Oseni
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne B Coopey
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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2
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Weinzierl A, Schmauss D, Brucato D, Harder Y. Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind? J Clin Med 2022; 11:jcm11113079. [PMID: 35683465 PMCID: PMC9181810 DOI: 10.3390/jcm11113079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 01/15/2023] Open
Abstract
Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.
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Affiliation(s)
- Andrea Weinzierl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Germany;
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland; (D.S.); (D.B.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
- Correspondence:
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Van Belleghem S, Mahadik B, Snodderly K, Mote Z, Jiang B, Yu JR, McLoughlin S, He X, Nam AJ, Fisher JP. Dual Extrusion Patterning Drives Tissue Development Aesthetics and Shape Retention in 3D Printed Nipple-Areola Constructs. Adv Healthc Mater 2021; 10:e2101249. [PMID: 34617414 PMCID: PMC8665136 DOI: 10.1002/adhm.202101249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/16/2021] [Indexed: 12/11/2022]
Abstract
Breast cancer and its most radical treatment, the mastectomy, significantly impose both physical transformations and emotional pain in thousands of women across the globe. Restoring the natural appearance of a nipple-areola complex directly on the reconstructed breast represents an important psychological healing experience for these women and remains an unresolved clinical challenge, as current restorative techniques render a flattened disfigured skin tab within a single year. To provide a long-term solution for nipple reconstruction, this work presents 3D printed hybrid scaffolds composed of complementary biodegradable gelatin methacrylate and synthetic non-degradable poly(ethylene) glycol hydrogels to foster the regeneration of a viable nipple-areola complex. In vitro results showcased the robust structural capacity and long-term shape retention of the nipple projection amidst internal fibroblastic contraction, while in vivo subcutaneous implantation of the 3D printed nipple-areola demonstrated minimal fibrotic encapsulation, neovascularization, and the formation of healthy granulation tissue. Envisioned as subdermal implants, these nipple-areola bioprinted regenerative grafts have the potential to transform the appearance of the newly reconstructed breast, reduce subsequent surgical intervention, and revolutionize breast reconstruction practices.
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Affiliation(s)
- Sarah Van Belleghem
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Bhushan Mahadik
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Kirstie Snodderly
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Zoe Mote
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Bin Jiang
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Justine R Yu
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Shannon McLoughlin
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Xiaoming He
- Fischell Department of Bioengineering, University of Maryland, College Park, 20742, USA
| | - Arthur J Nam
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, 21201, USA
| | - John P Fisher
- Fischell Department of Bioengineering, Center for Engineering Complex Tissues, University of Maryland, College Park, 20742, USA
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Comparing Nipple-sparing Mastectomy to Secondary Nipple Reconstruction: A Multi-institutional Study. Ann Surg 2021; 274:390-395. [PMID: 31469747 DOI: 10.1097/sla.0000000000003577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The primary aim of this study was to compare patient-reported outcomes (PROs) of women who underwent immediate implant-based breast reconstruction (IBBR) after receiving either: (1) nipple-sparing mastectomy (NSM) or (2) simple mastectomy with subsequent nipple reconstruction (SNR). BACKGROUND The goal of post-mastectomy breast reconstruction is to restore body image and quality-of-life after mastectomy, but removal of the nipple-areolar complex may have its own negative psychosocial consequences. NSM may have increased in popularity due to its perceived oncologic safety in many women and to reports of superior aesthetic results with this technique. Despite the increased utilization of NSM, few studies have evaluated the impact of NSM on PROs and complications in women undergoing immediate IBBR. METHODS We performed a secondary analysis of the Mastectomy Reconstruction Outcomes Consortium study, a multicenter, prospective cohort study that recruited patients between February 2012 and July 2015. The primary aim of this study was to compare PROs as measured by BREAST-Q scores between women who underwent IBBR after NSM versus SNR. The secondary aim was to compare complication rates. Mixed-effects regression models controlled for demographic and clinical covariates. RESULTS Of the 600 women in the study, 286 (47.7%) underwent NSM. After controlling for baseline patient characteristics, we found no significant differences in satisfaction with breast, psychosocial well-being, physical well-being or sexual well-being between women undergoing NSM versus SNR. Mastectomy type was not a significant predictor of complications or reconstructive failure. CONCLUSIONS Despite reports of superior aesthetics for NSM over simple mastectomy with nipple reconstruction in immediate IBBR, we found no significant differences at 2 years after reconstruction in patient satisfaction, quality-of-life, or complication rates.
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Viability of acellular biologic graft for nipple-areolar complex reconstruction in a non-human primate model. Sci Rep 2021; 11:15085. [PMID: 34301975 PMCID: PMC8302621 DOI: 10.1038/s41598-021-94155-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/05/2021] [Indexed: 11/09/2022] Open
Abstract
Many of the > 3.5 million breast cancer survivors in the US have undergone breast reconstruction following mastectomy. Patients report that nipple-areolar complex (NAC) reconstruction is psychologically important, yet current reconstruction techniques commonly result in inadequate shape, symmetry, and nipple projection. Our team has developed an allogeneic acellular graft for NAC reconstruction (dcl-NAC) designed to be easy to engraft, lasting, and aesthetically pleasing. Here, dcl-NAC safety and host-mediated re-cellularization was assessed in a 6-week study in rhesus macaque non-human primates (NHPs). Human-derived dcl-NACs (n = 30) were engrafted on the dorsum of two adult male NHPs with each animal's own nipples as controls (n = 4). Weight, complete blood counts, and metabolites were collected weekly. Grafts were removed at weeks 1, 3, or 6 post-engraftment for histology. The primary analysis evaluated health, re-epithelialization, and re-vascularization. Secondary analysis evaluated re-innervation. Weight, complete blood counts, and metabolites remained mostly within normal ranges. A new epidermal layer was observed to completely cover the dcl-NAC surface at week 6 (13-100% coverage, median 93.3%) with new vasculature comparable to controls at week 3 (p = 0.10). Nerves were identified in 75% of dcl-NACs (n = 9/12) at week 6. These data suggest that dcl-NAC is safe and supports host-mediated re-cellularization.
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Gilmour A, Cutress R, Gandhi A, Harcourt D, Little K, Mansell J, Murphy J, Pennery E, Tillett R, Vidya R, Martin L. Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol 2021; 47:2272-2285. [PMID: 34001384 DOI: 10.1016/j.ejso.2021.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/18/2021] [Accepted: 05/05/2021] [Indexed: 02/08/2023] Open
Abstract
Oncoplastic Breast Surgery has become standard of care in the management of Breast Cancer patients. These guidelines written by an Expert Advisory Group; convened by the Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), are designed to provide all members of the breast cancer multidisciplinary team (MDT) with guidance on the best breast surgical oncoplastic and reconstructive practice at each stage of a patient's journey, based on current evidence. It is hoped they will also be of benefit to the wide range of professionals and service commissioners who are involved in this area of clinical practice.
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Affiliation(s)
- A Gilmour
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, United Kingdom
| | - R Cutress
- University of Southampton and University Hospital Southampton, United Kingdom
| | - A Gandhi
- Manchester Academic Health Sciences Centre & Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - D Harcourt
- Centre for Appearance Research, University of the West of England, Bristol, United Kingdom
| | - K Little
- Liverpool Breast Unit, Liverpool University Foundation Trust, United Kingdom
| | - J Mansell
- Gartnavel General Hospital, Glasgow, United Kingdom
| | - J Murphy
- Manchester University Hospitals NHS Trust, United Kingdom
| | | | - R Tillett
- Royal Devon and Exeter NHS Trust, Exeter, United Kingdom
| | - R Vidya
- The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - L Martin
- Liverpool Breast Unit, Liverpool University Foundation Trust, United Kingdom.
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7
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Hammond JB, Teven CM, Bernard RW, Lucas HD, Casey WJ, Siebeneck ET, Kruger EA, Rebecca AM. 3D Nipple-Areolar Tattoo: It's Technique, Outcomes, and Utilization. Aesthetic Plast Surg 2021; 45:453-458. [PMID: 32968821 DOI: 10.1007/s00266-020-01967-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Three-dimensional (3D) nipple-areolar tattoo is a novel approach to nipple-areolar complex reconstruction for which little data exist. Our aim was to evaluate 3D nipple-areolar tattoo outcomes and investigate if patient factors, payer status, surgeries, or therapies affect tattoo utilization. METHODS Patients pursuing skin-sparing (SSM) or attempted nipple-sparing mastectomy (NSM) with breast reconstruction from 2008 to 2019 were reviewed. Outcomes included frequency of 3D tattoo, post-procedure complications (infections, or other local adverse sequelae), and rates, indications, and timing of revisions. Patient factors, payer status, surgeries, and adjuvant therapies underwent univariate analysis comparing rates of 3D tattoo and revisions. RESULTS A total of 191 patients were identified; median follow-up was 4 years. The majority of patients were white (165, 86%), married (146, 76%), and post-menopausal (97, 51%), with private insurance (156, 81%). Surgeries included SSM (172, 90%) or attempted NSM (19, 10%) with implant (154, 81%) or autologous reconstruction (37, 19%). Sixty-two patients (32%) underwent 3D nipple-areolar tattooing. No post-procedure complications occurred. After tattooing, 20 patients (32%) pursued revisions, the majority due to color fading (12, 60%). Average time from tattoo to completion of revisions was 5.6 months. Patients undergoing autologous reconstruction had a higher rate of 3D tattooing (p < 0.001). Adjuvant radiation led to a higher rate of revisions (p = 0.02). Patient factors, payer status, index mastectomy, and chemotherapy did not significantly affect rates of 3D tattooing or revisions. CONCLUSIONS 3D nipple-areolar tattoo utilization is likely unaffected by age, marriage, menopause, or payer status. Radiotherapy and color fading can lead to more revisions. 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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Affiliation(s)
| | - Chad M Teven
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Robert W Bernard
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Heather D Lucas
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - William J Casey
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Erwin A Kruger
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Alanna M Rebecca
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, AZ, USA.
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Spindler N, Ebel F, Briest S, Wallochny S, Langer S. Quality of Life After Bilateral Risk-Reducing Mastectomy and Simultaneous Reconstruction Using Pre-Pectoral Silicone Implants. Patient Prefer Adherence 2021; 15:741-750. [PMID: 33880017 PMCID: PMC8053496 DOI: 10.2147/ppa.s303208] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/13/2021] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Bilateral risk-reducing mastectomy (BRRM) can reduce the risk of developing breast cancer by up to 95% in women with increased exposure. Although survival is increased, mastectomies can adversely affect a patient physically, psychologically, and psychosexually. High health-related quality of life (HRQoL) is often achieved after simultaneous breast reconstruction (BR) following BRRM; however, data on the pre- and postoperative results of HRQoL are lacking. Therefore, we investigated the quality of life, esthetic outcome, and patient well-being after BRRM and simultaneous implant-based BR. PATIENTS AND METHODS Of the 35 patients who underwent skin-sparing or nipple-sparing mastectomy between May 2012 and December 2017 at a university hospital, only 22 completed the evaluation. Baseline data and data on previous operations and operation techniques were retrieved from the patient's charts. BREAST-Q and short form-36 health survey (SF-36) questionnaires were used to evaluate patient satisfaction and HRQoL. RESULTS SF-36 analysis showed a significantly higher score for pain (p=0.043) in our population than in the general female population. Comparing the pre- and postoperative BREAST-Q results, a significant decrease in the physical well-being of the chest (p=0.0179) and a slight improvement in breast satisfaction were observed (p=0.3266). All patients were well-satisfied with the postoperative outcome, reconstruction, and perioperative surgeon care. CONCLUSION Bilateral mastectomy with simultaneous BR using pre-pectoral implants is associated with an HRQoL similar to that of the healthy population. Although bilateral mastectomy may have an immense effect on the psychological, physical, and social aspects, immediate BR preserves the outer appearance and improves self-esteem.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
- Correspondence: Nick Spindler Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, Leipzig, 04103, GermanyTel +49-341-9717140Fax +49-341-9717139 Email
| | - Franziska Ebel
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Susanne Briest
- Department of Gynecology, Women’s and Children’s Centre, University Hospital Leipzig, Leipzig, Germany
| | - Sandra Wallochny
- Department of Gynecology, Women’s and Children’s Centre, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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Pashos NC, Graham DM, Burkett BJ, O'Donnell B, Sabol RA, Helm J, Martin EC, Bowles AC, Heim WM, Caronna VC, Miller KS, Grasperge B, Sullivan S, Chaffin AE, Bunnell BA. Acellular Biologic Nipple-Areolar Complex Graft: In Vivo Murine and Nonhuman Primate Host Response Evaluation. Tissue Eng Part A 2020; 26:872-885. [PMID: 31950890 PMCID: PMC7462026 DOI: 10.1089/ten.tea.2019.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/07/2020] [Indexed: 12/11/2022] Open
Abstract
There are more than 3 million breast cancer survivors living in the United States of which a significant number have undergone mastectomy followed by breast and nipple-areolar complex (NAC) reconstruction. Current strategies for NAC reconstruction are dependent on nonliving or nonpermanent techniques, including tattooing, nipple prosthetics, or surgical nipple-like structures. Described herein is a tissue engineering approach demonstrating the feasibility of an allogeneic acellular graft for nipple reconstruction. Nonhuman primate (NHP)-derived NAC tissues were decellularized and their extracellular matrix components analyzed by both proteomic and histological analyses. Decellularized NHP nipple tissue showed the removal of intact cells and greatly diminished profiles for intracellular proteins, as compared with intact NHP nipple tissue. We further evaluated the biocompatibility of decellularized grafts and their potential to support host-mediated neovascularization against commercially available acellular dermal grafts by performing in vivo studies in a murine model. A follow-up NHP pilot study evaluated the host-mediated neovascularization and re-epithelialization of onlay engrafted decellularized NAC grafts. The murine model revealed greater neovascularization in the decellularized NAC than in the commercially available control grafts, with no observed biocompatibility issues. The in vivo NHP model confirmed that the decellularized NAC grafts encourage neovascularization as well as re-epithelialization. These results support the concept that a biologically derived acellular nipple graft is a feasible approach for nipple reconstruction, supporting neovascularization in the absence of adverse systemic responses. Impact statement Currently, women in the United States most often undergo a mastectomy, followed by reconstruction, after being diagnosed with breast cancer. These breast cancer survivors are often left with nipple-areolar complex (NAC) reconstructions that are subsatisfactory, nonliving, and/or nonpermanent. Utilizing an acellular biologically derived whole NAC graft would allow these patients a living and permanent tissue engineering solution to nipple reconstruction.
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Affiliation(s)
- Nicholas C. Pashos
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Bioinnovation PhD Program, Tulane University, School of Science and Engineering, New Orleans, Louisiana, USA
- BioAesthetics Corporation, Research Triangle Park, North Carolina, USA
- Tulane National Primate Research Center, Covington, Louisiana, USA
| | - David M. Graham
- BioAesthetics Corporation, Research Triangle Park, North Carolina, USA
| | | | - Ben O'Donnell
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Bioinnovation PhD Program, Tulane University, School of Science and Engineering, New Orleans, Louisiana, USA
| | - Rachel A. Sabol
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joshua Helm
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Elizabeth C. Martin
- Department of Biological and Agricultural Engineering, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Annie C. Bowles
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - William M. Heim
- BioAesthetics Corporation, Research Triangle Park, North Carolina, USA
| | - Vince C. Caronna
- BioAesthetics Corporation, Research Triangle Park, North Carolina, USA
| | - Kristin S. Miller
- Department of Biomedical Engineering, Tulane University, School of Science and Engineering, New Orleans, Louisiana, USA
| | - Brooke Grasperge
- Tulane National Primate Research Center, Covington, Louisiana, USA
| | - Scott Sullivan
- Center for Restorative Breast Surgery, New Orleans, Louisiana, USA
| | - Abigail E. Chaffin
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Bruce A. Bunnell
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Tulane National Primate Research Center, Covington, Louisiana, USA
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, Louisiana, USA
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10
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Yang CQ, Ji F, Gao HF, Zhang LL, Yang M, Zhu T, Chen MY, Li JQ, Wang K. The Role of Sharp Dissection in Nipple-Sparing Mastectomy: A Safe Procedure with No Necrosis of the Nipple-Areolar Complex. Cancer Manag Res 2019; 11:10223-10228. [PMID: 31824192 PMCID: PMC6900313 DOI: 10.2147/cmar.s230787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/20/2019] [Indexed: 11/23/2022] Open
Abstract
Background Nipple-sparing mastectomy (NSM) is becoming increasingly accepted as a treatment for breast disease; however, nipple-areolar complex (NAC) necrosis, a frequent severe postoperative complication, inhibits the popularity of this procedure. This study reports the technical aspects and short-term postoperative outcomes of NSM. Methods A single-center, retrospective review of 110 patients treated with NSM at our institution from November 2015 to September 2018 was performed. The primary outcome was the incidence of NAC necrosis. Results A total of 130 NSMs performed on 110 patients were included in our study. Median patient age was 42 years. We performed a sharp dissection by using a scalpel, raising 3–5 mm thick flaps, and continuing onto the undersurface of the NAC. None of the 110 patients appeared to have NAC necrosis or mastectomy skin flap necrosis. However, discoloration or ischemia of the NAC with eschar formation presented between postoperative days 3 and 7 in six nipples; four nipples were ischemic, and two were discolored. No infection was detected in any of the 110 patients. All NACs were intact after an average follow-up of 30 months, and no local or systemic recurrence was detected in those breast cancer cases. Conclusion NSM can be safely performed in properly selected patients. Nipple necrosis was avoided using a special surgical technique, and other complications occurred at an acceptable rate.
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Affiliation(s)
- Ci-Qiu Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Fei Ji
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Hong-Fei Gao
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Liu-Lu Zhang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Mei Yang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Teng Zhu
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Min-Yi Chen
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jie-Qing Li
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Kun Wang
- Department of Breast Cancer, Cancer Center, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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Grinstein O, Krug B, Hellmic M, Siedek F, Malter W, Burke C, Schmutzler R, Maintz D, Rhiem K. Residual glandular tissue (RGT) in BRCA1/2 germline mutation carriers with unilateral and bilateral prophylactic mastectomies. Surg Oncol 2019; 29:126-133. [PMID: 31196476 DOI: 10.1016/j.suronc.2019.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/21/2019] [Accepted: 04/29/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Prophylactic mastectomy (PME) is increasingly performed in women carrying deleterious BRCA1 and BRCA2 germline mutations. The oncologic risk resulting from residual fibroglandular tissue (RGT) is unknown. METHODS All women who had received a mastectomy and at least one postoperative breast MRI, between 2006 and 2016 were extracted from the register of the Center for Hereditary Breast and Ovarian Cancer Cologne (CHBOC). The index MRI was evaluated in terms of basic clinical data and the morphological criteria of RGT. The RGT volume was measured in diameter and was semi-automatically evaluated using software. RESULTS We identified 169 women carrying BRCA1/2 mutations who underwent prophylactic and curative mastectomy: a total of 338 breasts. RGT was found in 128 of the 338 breasts (37.9%). 68 of the 128 breasts (53.1%) were related to bilateral PME, 37 (28.9%) to unilateral PME and 23 (18.0%) to curative mastectomy. RGT was predominantly unifocal and located in the retroareolar breast region. RGT was observed more often after bilateral PME (p < 0.0001). In this subgroup, the nipple-sparing mastectomy dominated (108 of 136, 79.4%), in contrast to 23 standard mastectomies (23 of 94, 24.5%) in the subgroup of curative mastectomy (23%). There was a trend towards higher amounts of RGT in surgical units with fewer mastectomies performed. During follow-up, two breast cancers were detected after bilateral and unilateral PME, respectively. CONCLUSIONS Our results suggest that the indication for surgery and in particular the selected surgical procedure affect the surgical outcome with respect to RGT. Oncological safety should not be neglected, especially in the high-risk group of BRCA1/2 mutation carriers.
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Affiliation(s)
- Olga Grinstein
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Germany
| | - Barbara Krug
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Germany.
| | - Martin Hellmic
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Germany
| | - Florian Siedek
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Germany
| | - Wolfram Malter
- Breast Center, Department of Gynaecology and Obstetrics, University Hospital of Cologne, Germany
| | - Christina Burke
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Germany
| | - Rita Schmutzler
- Center for Hereditary Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Germany
| | - David Maintz
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Germany
| | - Kerstin Rhiem
- Center for Hereditary Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Germany
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Corso G, De Lorenzi F, Vicini E, Pagani G, Veronesi P, Sargenti M, Magnoni F, Naninato P, Maisonneuve P, Sangalli C, Rietjens M, Galimberti V. Nipple-sparing mastectomy with different approaches: surgical incisions, complications, and cosmetic results. Preliminary results of 100 consecutive patients at a single center. J Plast Reconstr Aesthet Surg 2018; 71:1751-1760. [DOI: 10.1016/j.bjps.2018.07.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 06/04/2018] [Accepted: 07/28/2018] [Indexed: 12/29/2022]
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Roh TS, Kim JY, Jung BK, Jeong J, Ahn SG, Kim YS. Comparison of Outcomes between Direct-to-Implant Breast Reconstruction Following Nipple-Sparing Mastectomy through Inframammary Fold Incision versus Noninframammary Fold Incision. J Breast Cancer 2018; 21:213-221. [PMID: 29963118 PMCID: PMC6015980 DOI: 10.4048/jbc.2018.21.2.213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/17/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose In properly selected patients with breast cancer, nipple-sparing mastectomy (NSM) is generally considered safe by oncologic standards. We examined two groups of patients who underwent direct-to-implant (DTI) reconstruction after NSM, comparing complications encountered, revision rates, and aesthetic outcomes. The patients were stratified based on type of surgical incision and assigned to inframammary fold (IMF) and non-IMF groups. Methods We investigated 141 patients (145 breasts) subjected to NSM and immediate DTI reconstruction between 2013 and 2016. A total of 62 breasts (in 58 patients) were surgically removed via IMF incisions, with the other 83 breasts (in 83 patients) removed by non-IMF means. Results Complications associated with IMF (n=62) and non-IMF (n=83) incisions were as follows: skin necrosis (IMF, 9; non-IMF, 18); hematoma (IMF, 3; non-IMF, 4); seroma (IMF, 8; non-IMF, 4); mild capsular contracture (IMF, 4; non-IMF, 7); and tumor recurrence (IMF, 2; non-IMF, 8). Surgical revisions were counted as duplicates (IMF, 18; non-IMF, 38). Aesthetic outcomes following IMF incisions were rated as very good (44.2%), good (23.1%), fair (23.1%), or poor (9.6%). Conclusion IMF incision enables complete preservation of the nipple-areolar complex, yielding superior aesthetic results in immediate DTI breast reconstruction after NSM. The nature of incision used had no significant impact on postoperative complications or reoperation rates and had comparable oncologic safety to that of non-IMF incisions. IMF incisions produced the least visible scarring and did not affect breast shape. Most patients were satisfied with the aesthetic outcomes.
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Affiliation(s)
- Tai Suk Roh
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Yoon Kim
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bok Ki Jung
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Plastic & Reconstructive Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Woitek R, Pfeiler G, Farr A, Kapetas P, Furtner J, Bernathova M, Schöpf V, Clauser P, Marino MA, Pinker K, Baltzer PA, Helbich TH. MRI-based quantification of residual fibroglandular tissue of the breast after conservative mastectomies. Eur J Radiol 2018; 104:1-7. [PMID: 29857853 DOI: 10.1016/j.ejrad.2018.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Skin-sparing and nipple-sparing mastectomies (SSM; NSM) remove the breast's fibroglandular tissue (FGT), thereby reducing breast cancer risk. The postoperative presence of residual FGT (RFGT) is associated with remaining cancer risk. This study evaluated the role of MRI in the quantitative assessment of RFGT and its impact on the estimation of the remaining breast cancer risk. METHODS The postoperative MRI scans (following EUSOMA recommendations) of 58 patients who had undergone SSM or NSM between 2003 and 2013, as well as preoperative MRI scans that were available in 25 of these patients, were retrospectively evaluated for the presence and location of RFGT by three radiologists. Two different observers quantitatively assessed the volume and percentage of retromamillary and other RFGT (RFGTrm and RFGTother) were assessed. The Fisher's exact test, the Student's t-test, and intraclass coherence were used to compare patient groups and to assess reproducibility. RESULTS RFGT was found in 20% of all breasts and significantly more frequently after NSM than SSM (50% vs. 13%, p = .003). RFGTrm and RFGTother were more prevalent after NSM (p < 0.001; p = .127). RFGT ranged from 0.5 to 26% of the preoperative FGT, with higher percentages after NSM than SSM (p = .181). CONCLUSIONS The prevalence and percentage of RFGT found on MRI indicate a considerable remaining postoperative breast cancer risk in some women.
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Affiliation(s)
- Ramona Woitek
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Alex Farr
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - Panagiotis Kapetas
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Julia Furtner
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria Bernathova
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | | | - Paola Clauser
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Maria A Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, Policlinico Universitario G. Martino, University of Messina, Messina, Italy
| | - Katja Pinker
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria; Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Pascal A Baltzer
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria
| | - Thomas H Helbich
- Division of Molecular and Gender Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Austria.
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Manie T, Farahat A, Hashem T, Youssef MMG, Abdalwahab AR, Elattar I, El-Baradie TS. Preoperative estimation of cosmetic outcomes after immediate breast reconstruction with extended latissimus dorsi flap: A simple prediction model. JPRAS Open 2017; 15:10-17. [PMID: 32158792 PMCID: PMC7061624 DOI: 10.1016/j.jpra.2017.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 09/23/2017] [Indexed: 11/29/2022] Open
Abstract
Background The extended latissimus dorsi (ELD) flap can provide adequate volume for breast reconstruction without an implant. The aim of this study was to identify a simple method to estimate preoperatively if the ELD flap would provide enough volume for breast reconstruction and good cosmetic outcome. The proposed model was based on correlating the preoperative body mass index (BMI) and breast cup size. Methods This retrospective cohort study included 64 patients who underwent immediate breast reconstruction with ELD at the National Cancer Institute, Cairo University, between January 2014 and January 2016. Preoperative breast cup size and patients' BMI were recorded. The primary end point was cosmetic outcome score assessed by three independent breast surgeons and the patients. Correlation analysis was performed between the preoperative factors and final cosmetic outcome. Results Sixty-four patients underwent immediate reconstruction following skin-sparing mastectomy. BMI range was 23–38 kg/m2 with a median of 28. All patients with cup size A had aesthetically pleasing results. As the breast cup size increased, the favorable cosmetic outcomes were noted with lower BMI. All patients with BMI higher than 33 had unfavorable results. Conclusion Favorable cosmetic outcomes are expected after ELD reconstruction in patients with cup size A regardless of the BMI. As the breast cup size increases, favorable cosmetic outcomes are expected in patients with lower BMI than in those with higher BMI. At a BMI of 34, no favorable cosmetic outcomes are expected. The prediction model will be validated in a prospective study.
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Affiliation(s)
- T Manie
- Unit of Breast Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - A Farahat
- Unit of Breast Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - T Hashem
- Unit of Breast Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - M M G Youssef
- Unit of Breast Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - A R Abdalwahab
- Unit of Breast Surgery, National Cancer Institute, Cairo University, Cairo, Egypt
| | - I Elattar
- Department of Biostatistics and Cancer Epidemiology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - T S El-Baradie
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
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16
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Patient Satisfaction and Nipple-Areola Sensitivity After Bilateral Prophylactic Mastectomy and Immediate Implant Breast Reconstruction in a High Breast Cancer Risk Population: Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy. Ann Plast Surg 2017; 77:145-52. [PMID: 26076217 DOI: 10.1097/sap.0000000000000366] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prophylactic skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) both are associated with major risk reduction in women with high breast cancer risk. Skin-sparing mastectomy followed by nipple-areola complex (NAC) reconstruction is standard of care, but NSM is increasingly being performed. Preservation of the NAC in NSM may increase patient satisfaction. Therefore, we measured NAC sensitivity after NSM and compared patient satisfaction as well as body image after SSM with NSM. METHODS Women who underwent prophylactic bilateral SSM or NSM and immediate implant breast reconstruction between 2002 and 2012 were eligible. Patient satisfaction was assessed using the Breast-Q reconstruction questionnaire, body image using Hopwood's body image scale (BIS), and satisfaction with the (reconstructed) NAC using a study-specific questionnaire. In the NSM group, NAC sensitivity was assessed using Semmes Weinstein monofilaments with a 5-point scale and compared with NAC sensitivity in a nonoperated control group. RESULTS The SSM group comprised 25 women (50 SSMs) and the NSM group 20 women (39 NSMs). Median follow-up was 65 months in the SSM group compared with 27 months in the NSM group (P < 0.01). In univariable analyses, Breast-Q scores were favorable in the SSM group compared with the NSM group with trends for higher "satisfaction with breasts" (66.2 vs 56.6; P = 0.06) and "satisfaction with outcome" (76.1 vs 61.5; P = 0.09). Mean BIS score of 7.1/30 in the SSM group and 9.3/30 in the NSM group (P = 0.35). Adjusted for follow-up, there were no significant differences in Breast-Q scores, nor in BIS scores. Interestingly, satisfaction with the (reconstructed) NAC was similar after SSM and NSM. Nipple-areola complex sensitivity was lower in the NSM group (mean score, 1.9; 95% confidence interval, 1.5-2.3) compared with the control group (mean score, 4.7; 95% confidence interval, 4.6-4.9; P < 0.01). CONCLUSIONS Breast-Q scores regarding satisfaction with breasts and overall outcome were in favor of the SSM group. Residual NAC sensitivity after NSM was low. This suggests that SSM followed by NAC reconstruction is a balanced alternative to NSM. We observed no significant differences in body image and NAC-specific satisfaction between the NSM and SSM groups.
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17
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Quality-of-Life Outcomes Improve with Nipple-Sparing Mastectomy and Breast Reconstruction. Plast Reconstr Surg 2017; 140:219-226. [PMID: 28746266 DOI: 10.1097/prs.0000000000003505] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Loss of the nipple-areola complex can be psychologically and sexually devastating. Nipple-sparing mastectomy provides robust cosmetic results, but few studies have investigated the quality-of-life outcomes associated with it. METHODS The authors performed an institutional review board-approved retrospective study of 32 patients who underwent nipple-sparing mastectomy with implant-based or autologous reconstruction and 32 control patients who underwent non-nipple-sparing mastectomy with reconstruction matched by reconstruction type and operative period. They then compared premastectomy and postreconstruction responses to the BREAST-Q, a validated and breast reconstruction-specific quality-of-life questionnaire, within and between their study and control populations. RESULTS The nipple-sparing and non-nipple-sparing mastectomy groups were statistically similar in terms of mean age [49.9 ± 8.5 years (range, 36 to 69 years) and 47.7 ± 10.3 years (range, 26 to 68 years) (p = 0.29), respectively] and mean body mass index [24.3 ± 3.5 kg/m (range, 17.9 to 33.7 kg/m) and 25.5 ± 5.4 kg/m (range, 19.2 to 39.2 kg/m) (p = 0.29), respectively]. There were no significant between-group differences in occurrence of postreconstruction complications. The authors found significantly higher mean postreconstruction scores in the nipple-sparing mastectomy group within the Satisfaction with Breasts (p = 0.039) and the Satisfaction with Outcome (p = 0.017) domains. Finally, they noted higher median postreconstruction scores in the nipple-sparing mastectomy group within the Psychosocial Well-being (p = 0.043) and Satisfaction with Breasts (p = 0.004) domains. CONCLUSIONS Psychological concerns regarding malignancy may negatively impact premastectomy patient quality of life. Reconstructive surgery improves patients' postmastectomy quality of life. Nipple-sparing mastectomy appears to provide significantly better improvement in postreconstruction quality of life, specifically in the Satisfaction with Breasts and Satisfaction with Outcome domains of the BREAST-Q, compared with non-nipple-sparing mastectomies. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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18
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Pashos NC, Scarritt ME, Eagle ZR, Gimble JM, Chaffin AE, Bunnell BA. Characterization of an Acellular Scaffold for a Tissue Engineering Approach to the Nipple-Areolar Complex Reconstruction. Cells Tissues Organs 2017; 203:183-193. [PMID: 28125805 DOI: 10.1159/000455070] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 11/19/2022] Open
Abstract
A significant number of patients undergo mastectomies and breast reconstructions every year using many surgical-based techniques to reconstruct the nipple-areolar complex (NAC). Described herein is a tissue engineering approach that may permit a human NAC onlay graft during breast reconstruction procedures. By applying decellularization, which is the removal of cellular components from tissue, to an intact whole donor NAC, the extracellular matrix (ECM) structure of the NAC is preserved. This creates a biologically derived scaffold for cells to repopulate and regenerate the NAC. A detergent-based decellularization method was used to derive whole NAC scaffolds from nonhuman primate rhesus macaque NAC tissue. Using both histological and quantitative analyses for the native and decellularized tissues, the derived ECM graft was assessed. The bioactivity of the scaffold was evaluated following cell culture with bone marrow-derived mesenchymal stem cells (BMSCs). The data presented here demonstrate that scaffolds are devoid of cells and retain ECM integrity and a high degree of bioactivity. The content of collagen and glycosaminoglycans were not significantly altered by the decellularization process, whereas the elastin content was significantly decreased. The proliferation and apoptosis of seeded BMSCs were found to be approximately 65 and <1.5%, respectively. This study characterizes the successful decellularization of NAC tissue as compared to native NACs based on structural protein composition, lubricating protein retention, the maintenance of adhesion molecules, and bioactivity when reseeded with cells. These histological and quantitative analyses provide the foundation for a novel approach to NAC reconstruction.
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Affiliation(s)
- Nicholas C Pashos
- Center for Stem Cell Research and Regenerative Medicine, Tulane University School of Medicine, New Orleans, LA, USA
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19
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Abstract
Over time, variations of mastectomy came up and started allowing the oncological safety and the possibility of an immediate breast reconstruction. Nipple sparing mastectomy (NSM) procedures have strongly increased in frequency and have become one of the best alternatives to treat breast cancer, also improving overall aesthetic outcomes and the achievement of contralateral breast symmetry. The nipple areola-complex (NAC) must be considered the identity of the breast concerning self-esteem of patients. This paper will remind the main anatomical topics around the nipple and breast ducts.
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Affiliation(s)
- Gustavo Zucca-Matthes
- 1 Department of Gynaecology, Obstetrics and Mastology, School of Medicine of Botucatu, UNESP, Distrito de Rubine of Bot, Botucatu-SP, Brazil ; 2 Breast Unit, Barretos Cancer Hospital, Rua Antenor Villela Duarte, 1331, Barretos - SP, 14784-400, Brazil ; 3 Breast Unit, Nossa Senhora das Gras G Hospital, Curitiba, PR, Brazil ; 4 Breast Unit, Universidade Fluminense, Niterne, Rio de Janeiro, Brazil
| | - Cícero Urban
- 1 Department of Gynaecology, Obstetrics and Mastology, School of Medicine of Botucatu, UNESP, Distrito de Rubine of Bot, Botucatu-SP, Brazil ; 2 Breast Unit, Barretos Cancer Hospital, Rua Antenor Villela Duarte, 1331, Barretos - SP, 14784-400, Brazil ; 3 Breast Unit, Nossa Senhora das Gras G Hospital, Curitiba, PR, Brazil ; 4 Breast Unit, Universidade Fluminense, Niterne, Rio de Janeiro, Brazil
| | - André Vallejo
- 1 Department of Gynaecology, Obstetrics and Mastology, School of Medicine of Botucatu, UNESP, Distrito de Rubine of Bot, Botucatu-SP, Brazil ; 2 Breast Unit, Barretos Cancer Hospital, Rua Antenor Villela Duarte, 1331, Barretos - SP, 14784-400, Brazil ; 3 Breast Unit, Nossa Senhora das Gras G Hospital, Curitiba, PR, Brazil ; 4 Breast Unit, Universidade Fluminense, Niterne, Rio de Janeiro, Brazil
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Benson JR, Dumitru D, Malata CM. Oncologic safety of conservative mastectomy in the therapeutic setting. Gland Surg 2016; 5:37-46. [PMID: 26855907 DOI: 10.3978/j.issn.2227-684x.2015.05.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Conservative mastectomy is a form of nipple-sparing mastectomy which is emerging as a surgical option for selected breast cancer patients. This technique differs from subcutaneous mastectomy which is well established as a technique for risk reduction but leaves behind a finite remnant of retro-areolar breast tissue. Clinical trials have confirmed the efficacy and safety of breast conservation therapy for smaller localised breast tumors whereby a variable amount of surrounding normal tissue is excised with administration of breast radiotherapy post-operatively. Conservative mastectomy aims to remove all breast tissue with dissection continued into the core of the nipple. However, the indication for conservative mastectomy remains to be defined but generally includes tumors of modest size located at least 2 cm away from the nipple. Patients undergoing conservative mastectomy do not necessarily receive adjuvant radiotherapy and this may only be intra-operative irradiation of the nipple-areola complex (NAC). Preservation of the NAC as part of a skin-sparing mastectomy in patients who might otherwise require standard mastectomy is of unproven safety from an oncologic perspective but is associated with enhanced cosmetic outcomes and quality-of-life. The advent of conservative mastectomy has coincided with a trend for "maximal surgery" with bilateral extirpation of all breast tissue in conjunction with immediate breast reconstruction. It is essential there is no compromise of local recurrence and survival in terms of ipsilateral breast cancer treatment. Further studies are required to clarify the indications for conservative mastectomy and confirm oncologic equivalence to either wide local excision and breast irradiation or conventional/skin-sparing mastectomy with sacrifice of the nipple areola complex.
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Affiliation(s)
- John R Benson
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
| | - Dorin Dumitru
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
| | - Charles M Malata
- 1 Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK ; 2 Faculty of Medical Science, Anglia Ruskin University, Cambridge and Chelmsford, CM1 1SQ, UK
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Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, Roviello F, D'Aniello C, Nisi G. Nipple-areola complex reconstruction techniques: A literature review. Eur J Surg Oncol 2016; 42:441-65. [PMID: 26868167 DOI: 10.1016/j.ejso.2016.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/07/2015] [Accepted: 01/06/2016] [Indexed: 11/30/2022] Open
Abstract
Many techniques for nipple-areola complex (NAC) reconstruction are described. Clarity is required on the currently available options. Since a complete list of all the techniques described until now is not available, a possibly comprehensive literature overview was carried out from 75 papers (years 1946-2015). The local flap was the most frequently described technique for the nipple reconstruction with no significant difference in complications' rate among the various types of techniques. Complications in nipple reconstruction were 46.9% after graft, 7.9% after local flap, and 5.3% in case of flaps with autologous graft/alloplastic/allograft augmentation, while complications in areola reconstruction were 10.1% after graft, and 1.6% after areola tattoo. Flaps appear to be more reliable than grafts in nipple reconstruction, while tattoo is thought to be safer than graft in areola reconstruction. The loss of projection, although considerable (45%-75%), had not significant impact on patients' satisfaction. Due to contraction, overcorrection of 25-50% of the desired result is advisory when adopting local flaps, in order to prevent loss of projection. The use of flaps with autologous graft/alloplastic/allograft augmentation (cartilage, fat, calcium hydroxylapatite, acellular dermal matrix, polymethylmethacrylate, biologic collagen) showed a minor loss of nipple projection but may expose to a relative increased number of postoperative flap necrosis.
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Affiliation(s)
- A Sisti
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy.
| | - L Grimaldi
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - J Tassinari
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - R Cuomo
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - L Fortezza
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - M A Bocchiotti
- Department of Plastic Surgery, University of Turin, San Giovanni Battista Hospital, Turin, Italy
| | - F Roviello
- Oncologic Surgery, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - C D'Aniello
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
| | - G Nisi
- Plastic Surgery Division, General and Specialist Surgery Department, University of Siena, Siena, Italy
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Nipple-areolar Complex Reconstruction following Postmastectomy Breast Reconstruction: A Comparative Utility Assessment Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e380. [PMID: 25973358 PMCID: PMC4422211 DOI: 10.1097/gox.0000000000000133] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/14/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nipple-areola complex (NAC) reconstruction occurs toward the final stage of breast reconstruction; however, not all women follow through with these procedures. The goal of this study was to determine the impact of the health state burden of living with a reconstructed breast before NAC reconstruction. METHODS A sample of the population and medical students at McGill University were recruited to establish the utility scores [visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG)] of living with an NAC deformity. Utility scores for monocular and binocular blindness were determined for validation and comparison. Linear regression and Student's t test were used for statistical analysis, and significance was set at P < 0.05. RESULTS There were 103 prospective volunteers included. Utility scores (VAS, TTO, and SG) for NAC deformity were 0.84 ± 0.18, 0.92 ± 0.11, and 0.92 ± 0.11, respectively. Age, gender, and ethnicity were not statistically significant independent predictors of utility scores. Income thresholds of <$10,000 and >$10,000 revealed a statistically significant difference for VAS (P = 0.049) and SG (P = 0.015). Linear regression analysis showed that medical education was directly proportional to the SG and TTO scores (P < 0.05). CONCLUSIONS The absence of NAC in a reconstructed breast can be objectively assessed using utility scores (VAS, 0.84 ± 0.18; TTO, 0.92 ± 0.11; SG, 0.92 ± 0.11). In comparison to prior reported conditions, the quality of life in patients choosing to undergo NAC reconstruction is similar to that of persons living with a nasal deformity or an aging neck requiring rejuvenation.
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Management of central breast tumours with immediate reconstruction of the nipple-areola complex; a suggested guide. Breast 2015; 24:38-45. [DOI: 10.1016/j.breast.2014.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/27/2014] [Accepted: 11/04/2014] [Indexed: 11/22/2022] Open
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Rietjens M, Schorr MC, Lohsiriwat V. Part I Reconstruction Technique for Total Mastectomy. ATLAS OF BREAST RECONSTRUCTION 2015:1-5. [DOI: 10.1007/978-88-470-5519-3_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Lohsiriwat V, Petit J. Nipple Sparing Mastectomy: from prophylactic to therapeutic standard. Gland Surg 2014; 1:75-9. [PMID: 25083428 DOI: 10.3978/j.issn.2227-684x.2012.06.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 06/20/2012] [Indexed: 01/24/2023]
Affiliation(s)
- Visnu Lohsiriwat
- 1 Department of Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy ; 2 Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, Thailand
| | - JeanYves Petit
- 1 Department of Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy ; 2 Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, Thailand
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Baltzer HL, Alonzo-Proulx O, Mainprize JG, Yaffe MJ, Metcalfe KA, Narod SA, Warner E, Semple JL. MRI Volumetric Analysis of Breast Fibroglandular Tissue to Assess Risk of the Spared Nipple in BRCA1 and BRCA2 Mutation Carriers. Ann Surg Oncol 2014; 21:1583-8. [DOI: 10.1245/s10434-014-3532-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Indexed: 11/18/2022]
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Nipple-areola-complex sparing mastectomy: five years of experience in a single centre. Updates Surg 2013; 65:289-94. [DOI: 10.1007/s13304-013-0226-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
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Georgiou CA, Ihrai T, Chamorey E, Flipo B, Chignon-Sicard B. A formula for implant volume choice in breast reconstruction after nipple sparing mastectomy. Breast 2012; 21:781-2. [PMID: 23079561 DOI: 10.1016/j.breast.2012.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022] Open
Abstract
Implant choice after Nipple Sparing Mastectomy (NSM) is a problematic perioperative issue. In this retrospective study, the authors searched for a correlation between mastectomy weight and implant volume choice after NSM. A mathematical expression of this correlation was found that might help surgeons decide implant volume after NSM.
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Affiliation(s)
- Charalambos A Georgiou
- Breast Cancer and Reconstructive Surgery Unit, Centre Antoine Lacassagne, 33 Avenue de Valombrose, 06189 Nice cedex 2, France.
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