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Daly AE, Anderman KJ, Smith BL. ASO Author Reflections: Positive Nipple Margins in Nipple-Sparing Mastectomy: Management of Nipples Containing Cancer or Atypia. Ann Surg Oncol 2024:10.1245/s10434-024-15426-2. [PMID: 38806759 DOI: 10.1245/s10434-024-15426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/30/2024]
Affiliation(s)
- Abigail E Daly
- Breast Section, Division of GI and Oncologic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kyle J Anderman
- 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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Citgez B, Yigit B, Bas S. Oncoplastic and Reconstructive Breast Surgery: A Comprehensive Review. Cureus 2022; 14:e21763. [PMID: 35251834 PMCID: PMC8890601 DOI: 10.7759/cureus.21763] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/13/2022] Open
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Garstka M, Henriquez A, Kelly BN, Webster A, Khubchandani JA, Hughes K, Nguyen A, Oseni T, Specht M, Coopey SB, Gadd MA, Smith BL. How Protective are Nipple-Sparing Prophylactic Mastectomies in BRCA1 and BRCA2 Mutation Carriers? Ann Surg Oncol 2021; 28:5657-5662. [PMID: 34296361 DOI: 10.1245/s10434-021-10445-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) is now routinely offered to BRCA mutation carriers for risk reduction. We assessed the rates of ipsilateral cancer events after prophylactic and therapeutic NSM in BRCA1 and BRCA2 mutation carriers. METHODS BRCA1 and BRCA2 mutation carriers undergoing NSM from October 2007 to June 2019 were identified in a single-institution prospective database, with variants of unknown significance being excluded. Patient, tumor, and outcomes data were collected. Follow-up analysis was by cumulative breast-years (total years of follow-up of each breast) and woman-years (total years of follow-up of each woman). RESULTS Overall, 307 BRCA1 and BRCA2 mutation carriers (160 BRCA1, mean age 41.4 years [range 21-65]; and 147 BRCA2, mean age 43.8 years [range 23-65]) underwent 607 NSMs, with a median follow-up of 42 months (range 1-143). 388 bilateral prophylactic NSMs had 744 cumulative woman-years of follow-up, with no new cancers seen (< 0.0013 new cancers per woman-years); 251 BRCA1 prophylactic NSMs had 1034 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0010 per breast-year); 66 BRCA1 therapeutic NSMs had 328 cumulative breast-years of follow-up, with one ipsilateral cancer recurrence not directly involving the nipple or areola (0.0030 per breast-year); 237 BRCA2 prophylactic NSMs had 926 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0011 per breast-year); and 53 BRCA2 therapeutic NSMs had 239 cumulative breast-years of follow-up, with two ipsilateral recurrent cancers, neither of which directly involved the nipple or areola (0.0084 per breast-year). CONCLUSIONS The risk of new ipsilateral breast cancers is extremely low after NSM in BRCA1 and BRCA2 mutation carriers. NSM is an effective risk-reducing strategy for BRCA gene mutations.
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Affiliation(s)
- Meghan Garstka
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Anthony Henriquez
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Bridget N Kelly
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Alexandra Webster
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Jasmine A Khubchandani
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Kevin Hughes
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Anvy Nguyen
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Tawakalitu Oseni
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michelle Specht
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Suzanne B Coopey
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Michele A Gadd
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA
| | - Barbara L Smith
- Breast Program, Division of Surgical Oncology, Massachusetts General Hospital, MGH Center for Breast Cancer, Boston, MA, USA.
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Razavi SA, Hart AL, Carlson GW. Ischemic Complications After Bilateral Nipple-sparing Mastectomy and Implant-based Reconstruction: A Critical Analysis. Ann Plast Surg 2021; 86:S526-S531. [PMID: 34100810 DOI: 10.1097/sap.0000000000002703] [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: 11/27/2022]
Abstract
PURPOSE Nipple-sparing mastectomy (NSM) has a higher incidence of mastectomy skin flap necrosis (MSFN) than skin-sparing mastectomy. The purpose of this study is to analyze predisposing factors for nipple and skin necrosis after bilateral NSM with immediate implant reconstruction. METHODS Sixty-two consecutive patients (124 breasts) from a single breast/plastic surgeon underwent bilateral NSM with immediate implant-based breast reconstruction were included. Factors influencing MSFN were analyzed. RESULTS The mean age was 45.7 years, and mean body mass index was 22.9. Reconstructive methods were as follows: tissue expander (TE), 76 (61.3%); and direct to implant, 48 (38.7%). Mastectomy skin flap necrosis occurred in 39 (31.5%) breasts, nipple necrosis 38 and skin flap necrosis 19. Thirty-seven breasts healed uneventfully, and 2 (1.6%) required reoperation. Cancer pathology, mastectomy weight greater than 279 g, TE reconstruction, and nipple-notch (N-N) distance greater than 23 cm were predictive of nipple necrosis on univariate analysis. The mean mastectomy weight (380.1 g vs 220.7 g, P < 0.0001), N-N distance greater than 23 cm (30 vs 0, P < 0.0001), and mean implant size (490 cm3 vs 373 cm3, P < 0.0001) were greater in the TE group. On logistic regression model controlling for all significant variables, predictors of MSFN were as follows: diagnosis of cancer (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.41-8.03; P = 0.006), TE reconstruction (OR, 2.87; 95% CI, 1.03-8.03; P = 0.04), and N-N distance (OR, 1.31; 95% CI, 1.03-1.66; P = 0.03). CONCLUSIONS Mastectomy skin flap necrosis after NSM and implant reconstruction is common. In this series, only 2 (1.6%) cases required surgical intervention with no implant loss. Treatment of breast cancer, TE reconstruction, and increasing N-N notch distance were positive predictors of MSFN.
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Affiliation(s)
- S Amir Razavi
- From the Division of Plastic Surgery, Emory University School of Medicine, Atlanta, GA
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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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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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Kim HJ, Lee SJ, Lee JH, Shin SH, Kim SH, Kim JH, Suh IS. Breast reconstruction after complications following breast augmentation with massive filler injections. Medicine (Baltimore) 2020; 99:e21516. [PMID: 32871998 PMCID: PMC7437735 DOI: 10.1097/md.0000000000021516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Breast filler injections are less commonly used due to their associated complications, such as pain and foreign body reactions. Yet, these fillers are often administered illegally, resulting in aesthetic or life-threatening complications. These are treated by removing the foreign material, and the breasts are reconstructed using silicone implants or autologous tissue/fat injection. PATIENT CONCERNS Case 1. A 45-year-old woman with polyacrylamide gel injections in both breasts visited our clinic for breast pain and tenderness. Grade I ptosis was observed in each breast, without skin necrosis and discoloration. Case 2. A 51-year-old woman, with unknown breast filler injections, visited our clinic for painful masses. Intraoperatively, massive amounts of foreign material had severely infiltrated the nearby tissues; thus, an immediate breast reconstruction could not be performed. Three months later, severe deformities including shrinkage and irregular breast skin surfaces were observed. DIAGNOSIS Case 1. Multiple cystic lesions, fluid collection in the retromammary spaces, and diffuse infiltration were observed on mammography, computed tomography, and ultrasonography. Case 2. Multiple cystic lesions, calcified areas, and diffuse infiltrations in the axillae and retromammary spaces were observed on mammography, computed tomography, and ultrasonography. INTERVENTIONS Case 1. The foreign material was removed and the breasts were reconstructed using silicone implants into subpectoral pocket with acellular dermal matrices (Alloderm, Lipocell Corporation). Case 2. A delayed reconstruction was undertaken using silicone implants covered by latissimus dorsi muscle flaps, 3 months after the foreign material removal. OUTCOMES Case 1. The foreign material was removed and there were no complications such as foreign body reaction, capsular contracture. Ptosis was corrected and both breasts were symmetric with proper projection. Case 2. Residual foreign material was removed and there were no complications such capsular contracture, implant malposition. CONCLUSION Massive injections of foreign materials into the breast can cause severe infiltration and associated foreign body reactions. By a near-complete removal of the foreign materials and breast reconstruction using silicone implants, we achieved satisfactory results, without complications such as wound disruption, capsular contracture, and implant malposition.
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Heinzen RN, de Barros ACSD, Carvalho FM, Aguiar FN, Nimir CDCBA, Jacomo AL. Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal. Gland Surg 2020; 9:637-646. [PMID: 32775253 DOI: 10.21037/gs-20-405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts. Methods In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated. Results IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219). Conclusions In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.
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Affiliation(s)
- Rebeca Neves Heinzen
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | - Fernando Nalesso Aguiar
- Discipline of Pathologic Anatomy, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Alfredo Luiz Jacomo
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
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Metere A, Fabiani E, Lonardo MT, Giannotti D, Pace D, Giacomelli L. Nipple-Sparing Mastectomy Long-Term Outcomes: Early and Late Complications. MEDICINA-LITHUANIA 2020; 56:medicina56040166. [PMID: 32276470 PMCID: PMC7230840 DOI: 10.3390/medicina56040166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Abstract
Background and Objectives: The surgical choice treatment of the breast cancer mostly depends on the stage of the disease. In the last years, breast cancer surgery has moved from being destructive to being more respectful of the anatomical and physiological integrity of the gland. The aim of the breast surgery should be finalized to obtain the best aesthetic and functional results, respecting the principles of oncologic radicality. The present study is a retrospective analysis aimed to evaluate the long-term outcomes of a conservative technique like the nipple-sparing mastectomy. Materials and Methods: We observed 894 patients with a median age of 47.5 years old, underwent nipple-sparing mastectomy between 2002–2017. The data acquired include population and tumor characteristics, patient reconstructive outcomes, including locoregional, regional, and distant metastases; other variables, among nipple–areola complex necrosis and infection were collected. Results: The complications detected were considered as “early” within 1 month later the nipple-sparing mastectomy or “late” after this time. The overall complications rate (early and late) and the overall survival and the relapses detected by this study were comparable with those reported in the literature. In order to identify factors that correlate with complications, either early or later, it has been processed an evaluation of the univariate analysis showing adjuvant chemotherapy as the only predictive factor for late complications, while we encountered no predictors for early complications. Conclusions: The present study adds to the data already present in literature, demonstrating that the nipple-sparing mastectomy is a safe procedure, providing good oncological and aesthetic results in patients carefully selected.
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Affiliation(s)
- Alessio Metere
- Surgical Sciences Department, “Sapienza” University of Rome, Viale Regina Elena 261, 00161 Rome, Italy;
- Correspondence:
| | - Elisabetta Fabiani
- Emergency Department, Aurelia Hospital, Via Aurelia, 860, 00165 Rome, Italy;
| | - Maria Teresa Lonardo
- Department of Surgery, Ospedali Riuniti di Anzio-Nettuno, Via Cupa dei Marmi, 00042 Anzio, Italy;
| | - Domenico Giannotti
- Department of Surgery, Ospedale Belcolle, Strada Sammartinese snc, 01100 Viterbo, Italy;
| | - Daniela Pace
- Valmontone Hospital, Via dei Lecci snc, 00038 Valmontone, Italy;
| | - Laura Giacomelli
- Surgical Sciences Department, “Sapienza” University of Rome, Viale Regina Elena 261, 00161 Rome, Italy;
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Djohan R, Knackstedt R. Collaboration between breast and reconstructive surgery in optimizing outcomes for women with breast cancer. Breast J 2019; 26:42-46. [PMID: 31876102 DOI: 10.1111/tbj.13723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/25/2019] [Indexed: 11/27/2022]
Abstract
Performing successful breast reconstruction after mastectomy requires communication and collaboration between the breast and reconstruction surgery teams. This allows for oncologic safety while providing esthetic and functional reconstruction. In this article, we discuss the numerous techniques we have adopted successfully into our breast reconstructive practice that were possible due to this collaboration including prophylactic lymphaticovenous bypass (LVB), tumor ultrasound-guided incision (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve identification at time of mastectomy to allow for sensate reconstruction, and the prevention of chronic pain and strategic oncoplasty.
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Affiliation(s)
- Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
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Nipple-Sparing Mastectomy and Prepectoral Implant/Acellular Dermal Matrix Wrap Reconstruction in Large Ptotic Breasts. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2289. [PMID: 31942332 PMCID: PMC6952144 DOI: 10.1097/gox.0000000000002289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/15/2019] [Indexed: 11/26/2022]
Abstract
Nipple-sparing mastectomy (NSM) with simultaneous prepectoral direct to implant reconstruction and acellular dermal matrix (ADM) is increasingly offered to patients opting for prophylactic or therapeutic mastectomies. The recent introduction of prepectoral implant/ADM in the armamentarium of breast reconstruction has proven to reduce pain and animation deformity. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat. More often they would require secondary corrective procedures and can experience high failure rate and unsatisfactory outcomes. The authors present their experience in utilizing a bipedicled nipple-areola complex dermal flap through Wise pattern to achieve a successful NSM with prepectoral implant/ADM (Braxon) wrap (IBW) as a single stage in patients with large ptotic breasts. Patients seeking NSM with large ptotic breasts were included in the study in the period between 2016 and 2018. They were offered a single-stage Wise pattern NSM and immediate prepectoral IBW breast reconstruction. The technique and outcomes were recorded. Sixteen reconstructions were performed in 8 women with a median age of 32 years (range, 27-50 years) and a median body mass index of 32 kg/m2 (range, 29-39 kg/m2). The resected breasts weight ranged from 750 to 1,600 g (median, 890 g). All procedures were completed successfully with no nipple-areola complex necrosis or failure experienced during the follow-up period (range, 3-24 months) with all patients reported excellent satisfaction. The authors' results demonstrate that this technique could be safely planned for NSM in large ptotic breasts with excellent durable outcomes.
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Huang Z, Chen K, Zhu L, Zeng J, Zhou Z, Li S. [Effectiveness of endoscopic nipple-sparing mastectomy combined with immediate breast reconstruction via axillary incision]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 32:1458-1462. [PMID: 30417625 DOI: 10.7507/1002-1892.201804027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To introduce an surgical technique of endoscopic nipple-sparing mastectomy (NSM) combined with immediate breast reconstruction through simple single-port access that placed in axillary incision. Methods Between January 2017 and February 2018, 15 female patients with breast cancer (stageⅠ in 5 cases and stage Ⅱ in 10 cases) were treated with endoscopic NSM combined with immediate breast reconstruction through simple single-port access that placed in axillary incision. They were 27-45 years old (mean, 37.5 years). The disease duration ranged from 1 to 24 months (mean, 8 months). The tumor located at the left breast in 8 cases and at the right breast in 7 cases. The diameter of tumor ranged from 1.5 to 3.0 cm (mean, 2.6 cm). The distance between tumor and nipple was 1.8-4.0 cm (mean, 2.3 cm). Results After operation, the nipple epidermal necrosis occurred in 1 case, and subcutaneous effusion in 1 case. No subcutaneous emphysema or skin flap necrosis occurred. Postoperative pathological examination showed that 1 case was nipple involvement and was treated with nipple resection. All patients were followed up 7-17 months (mean, 11 months). According to the Harris assessment criteria for appearance of reconstructed breast, there were 4 cases of excellent, 10 cases of good, and 1 case of poor. No tumor recurrence or metastasis occurred during follow-up. Conclusion It is a safe and feasible method of endoscopic NSM combined with immediate breast reconstruction through simple single-port access that placed in axillary incision, and can obtain good cosmetic results. It is a new option to breast reconstruction.
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Affiliation(s)
- Zhenqiang Huang
- Department of General Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China;Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510120, P.R.China
| | - Kai Chen
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510120, P.R.China
| | - Liling Zhu
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510120, P.R.China
| | - Jianfeng Zeng
- Department of General Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Zhiping Zhou
- Department of General Surgery, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Shunrong Li
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou Guangdong, 510120,
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Kozak K, Wojcik R, Czerwonka M, Mandziuk S, Madej-Czerwonka B. Oncoplastic breast surgery techniques - a new look at surgical treatment of breast cancer. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2018. [DOI: 10.1515/cipms-2018-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Breast cancer is the most common cancer among Polish women [1], thus, the problem of surgical treatment of breasts, especially with regard to conserving and/or reconstruction surgery, is extensively discussed. Currently, in Poland, efforts are made to increase the number of oncologic and reconstructive breast centers which offer specialized treatment of this cancer, the so-called ‘Breast Units’ [1]. This paper analyzes methods of reconstructions, discusses the techniques used in particular types of surgeries and additionally informs the reader of the oncological aspects of the procedures. Based on literature, statistical data of breast reconstructions from Poland and the world are presented. Moreover, complications and psychological aspects of mammary gland surgery are dealt with, and the aesthetic effects of breast reconstructions are discussed. To support of our findings, we also present selected clinical cases from the oncological and reconstructive point of view.
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Affiliation(s)
- Krzysztof Kozak
- Chair and Department of Human Anatomy , Medical University of Lublin , Jaczewskiego 4, 20-090 Lublin , Poland
- Breast Surgery Department of the Cardinal Rev. Wyszynski’s Voivodship Specialistic Hospital in Lublin , Poland
| | - Rafal Wojcik
- Chair and Department of Human Anatomy , Medical University of Lublin , Jaczewskiego 4, 20-090 Lublin , Poland
- Breast Surgery Department of the Cardinal Rev. Wyszynski’s Voivodship Specialistic Hospital in Lublin , Poland
| | - Maciej Czerwonka
- Chair and Department of Human Anatomy , Medical University of Lublin , Jaczewskiego 4, 20-090 Lublin , Poland
- Breast Surgery Department of the Cardinal Rev. Wyszynski’s Voivodship Specialistic Hospital in Lublin , Poland
| | - Slawomir Mandziuk
- Chair and Clinic of Pneumology, Oncology and Allergology , Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954 Lublin , Poland
| | - Barbara Madej-Czerwonka
- Chair and Department of Human Anatomy , Medical University of Lublin , Jaczewskiego 4, 20-090 Lublin , Poland
- Breast Surgery Department of the Cardinal Rev. Wyszynski’s Voivodship Specialistic Hospital in Lublin , Poland
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Affiliation(s)
- Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Radovanovic Z, Ranisavljevic M, Radovanovic D, Vicko F, Ivkovic-Kapicl T, Solajic N. Nipple-Sparing Mastectomy with Primary Implant Reconstruction: Surgical and Oncological Outcome of 435 Breast Cancer Patients. Breast Care (Basel) 2018; 13:373-378. [PMID: 30498425 DOI: 10.1159/000489317] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to examine the incidence of surgical complications associated with nipple-sparing mastectomy (NSM) with primary implant reconstruction, analyze risk factors for early and late surgical complications of NSM, and determine the incidence of local recurrences and the safety of sparing the nipple-areola complex (NAC). Methods This retrospective cohort study included 435 patients with 441 NSM procedures over a period of 9 years (2004-2012). All surgical complications and the oncological outcome were recorded during follow-up. Results The most common early surgical complication was skin flap ischemia/necrosis (26 patients, 5.9%). Prosthesis explantation due to complications was carried out in 11 (2.5%) cases. Neoadjuvant chemotherapy, implant size >500 ml, diabetes mellitus, body mass index > 25 kg/m2, and incisions other than lateral were risk factors for early complications (p < 0.001). The NAC excision rate was 5.4% (24 cases) due to confirmed presence of cancer cells in the subareolar tissue. Capsular contracture as a late complication occurred in 33 (7.48%) cases. Local relapse occurred in 32 (7.3%) patients. Distant metastases were diagnosed in 68 (15.6%) patients, and 53 (12.2%) patients died during the follow-up period. Conclusions NSM with immediate implant reconstruction has an acceptable morbidity rate and is an oncologically and surgically appropriate treatment for most women requiring mastectomy.
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Affiliation(s)
- Zoran Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Milan Ranisavljevic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Dragana Radovanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Ferenc Vicko
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Tatjana Ivkovic-Kapicl
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Nenad Solajic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
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16
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Ashikari AY, Kelemen PR, Tastan B, Salzberg CA, Ashikari RH. Nipple sparing mastectomy techniques: a literature review and an inframammary technique. Gland Surg 2018; 7:273-287. [PMID: 29998077 DOI: 10.21037/gs.2017.09.02] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nipple sparing mastectomy (NSM) has quickly become an accepted technique for patients with selected cancers and for risk reducing surgery. Much of its surgical acceptance over the last decade has been based on the low risk of nipple areolar complex (NAC) occurrence in breast cancer patients. Improved patient satisfaction due to improved cosmetic outcomes with reconstruction have also driven its popularity. We reviewed current English journals to determine the NSM techniques which achieve the lowest complications, best outcomes, and best patient satisfaction. We researched studies showing reductions in complications with improved surgical techniques and patient selection which have been implicated in improved results. In the studies reviewed, incision placement, away from the nipple, resulted in the lowest rates of ischemic nipple complications and the best cosmetic outcomes. The effect of other factors such as surgeon experience and thickness of skin flap development were more difficult to prove. Leaving a 2-3 mm rim of tissue around the nipple bundle was shown to help preserve the nipple vascularity. Lower complication rates with improved outcomes and patient satisfaction were reported in the literature in patients with B or smaller cup sizes, non-smokers, and patients with lower body mass index (BMI). Incision placement, away from the nipple, with preservation of a 2-3 mm rim of tissue around the nipple bundle along with careful patient selection were the most significant variables reviewed which helped to lower complications rates of NSM. Coordinated surgical planning with the breast and plastic surgeons to determine the best surgical approach for each individual patient is necessary to obtain the best results. Although short-term oncologic follow-up seems to be acceptable, longer follow-up will still be needed to define the best breast cancer surgical candidates for the nipple sparing approach.
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Affiliation(s)
- Andrew Y Ashikari
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Pond R Kelemen
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Bahar Tastan
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA
| | - C Andrew Salzberg
- Department of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Roy H Ashikari
- Ashikari Breast Center, St. John's Riverside Health System, Yonkers, NY, USA.,NYP/Hudson Valley Hospital, Cortlandt Manor, NY, USA.,Department of Surgery, New York Medical College, Valhalla, NY, USA
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17
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de Vita R, Buccheri EM. Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography. Gland Surg 2018; 7:258-266. [PMID: 29998075 DOI: 10.21037/gs.2018.04.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Nipple sparing mastectomy (NSM) is a psychologically effective and oncological safe procedure followed by immediate breast reconstruction. Methods Between January 2015 and September 2015 the authors conducted a retrospective review of 40 patients divided into two groups depending on breast volume and weight of mastectomy: group A, 20 patients with small breast; group B, 20 patients with medium breast for nipple sparing mastectomy and direct to implant (DTI) breast reconstruction using strict patient selection and a standardized surgical technique. The nipple areola complex/flap viability were analysed intraoperatively through the use of laser assisted indocyanine green (ICG) fluorescent angiography. Results A total of 44 procedures were followed-up for 24 months. Nineteen patients were assisted in DTI breast reconstruction by acellular dermal matrix (ADM) for inferior/lateral part of the implant coverage. Encouraging results are presented with a unique case of implant failure. Conclusions We report our retrospective experience corroborated by intraoperative laser assisted ICG fluorescent angiography to demonstrate the safety and reliability of the oncoplastic procedure proposed. We also advocate the central role of oncoplastic surgeon as "one man band" to manage breast cancer from the oncological procedure to the breast reconstruction.
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Affiliation(s)
- Roy de Vita
- Department of Plastic Surgery, Regina Elena Cancer Institute of Rome, Rome, Italy
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18
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Abstract
The introduction of more targeted systemic therapies, better screening modalities with earlier diagnosis and dramatically improved reconstructive techniques has allowed more minimally invasive approaches to breast surgery. The recent introduction of nipple sparing mastectomy (NSM) has dramatically improved the cosmetic outcomes and quality of life (QoL) for patients undergoing mastectomy. This technique involves preservation of both the skin envelope including the nipple areolar complex commonly through a barely visible inframammary skin incision followed by immediate breast reconstruction. An ideal candidate includes women with small breasts, absence of ptosis, low BMI and not actively smoking. High risk patients include those with radiation treatment, active smokers, macromastia, high BMI >30 kg/m2, grade 2 or 3 ptosis and active smokers. There are several new techniques to approach complex high risk patients which have expanded the candidates for NSM.
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Affiliation(s)
- Eleni Tousimis
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Michelle Haslinger
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
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19
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Mitchell SD, Willey SC, Beitsch P, Feldman S. Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry. Gland Surg 2018; 7:247-257. [PMID: 29998074 DOI: 10.21037/gs.2017.09.10] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM). Methods Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR. Results This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery. Conclusions NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.
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20
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Colwell AS, Christensen JM. Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction. Plast Reconstr Surg 2017; 140:44S-50S. [DOI: 10.1097/prs.0000000000003949] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Abstract
BACKGROUND Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors' experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results. METHODS A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor. RESULTS The authors' cohort included 1647 patients. Overall, 2023 nipple-sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors' cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated. CONCLUSIONS The authors' data suggest that proper patient selection and well-executed operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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22
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Merrill AL, Buckley J, Tang R, Brachtel E, Rai U, Michaelson J, Ly A, Specht MC, Yagi Y, Smith BL. A Study of the Growth Patterns of Breast Carcinoma Using 3D Reconstruction: A Pilot Study. Breast J 2016; 23:83-89. [PMID: 27860134 DOI: 10.1111/tbj.12688] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lumpectomy with microscopically clear margins is a safe and effective approach for surgical management of breast carcinoma. Margins are positive for tumor in 18-50% of lumpectomies, as it is not possible to accurately determine the shape or microscopic borders of a tumor preoperatively or intraoperatively. We examined the 3D microanatomy and growth patterns of common breast carcinoma subtypes to provide guidance for lumpectomy surgery. Prospective consent was obtained for the use of excess tissue from patients undergoing lumpectomy or mastectomy for breast carcinoma. Tissue blocks from nine breast carcinomas were serially sectioned. Hematoxylin and eosin-stained slides at 100 μm intervals were scanned using a Nanozoomer (Hamamatsu, Japan) microscopic-resolution scanner. Three-dimensional reconstructions of tumors were created from scanned images using Reconstruct, open-access software. Breast carcinoma subtypes demonstrated characteristic growth patterns within breast tissue, which may have implications for lumpectomy surgery. Invasive ductal carcinomas showed a spherical shape, with a spiculated surface representing tumor cells infiltrating into surrounding parenchyma. Ductal carcinoma in situ appeared to spread along the duct system, creating dilated, tortuous, tumor-filled ducts. The invasive lobular carcinomas examined had a haphazard, linear, infiltrative growth pattern, different from the shape seen in ductal carcinomas. Our preliminary work suggests that invasive ductal and invasive lobular carcinomas appear to have distinct growth patterns in three dimensions and ductal carcinoma in situ appears to grow in a linear fashion along the duct network. The microanatomy studies described have the potential to guide refinements in breast lumpectomy technique.
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Affiliation(s)
- Andrea L Merrill
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Julliette Buckley
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Rong Tang
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Elena Brachtel
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Upahvan Rai
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - James Michaelson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle C Specht
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Yukako Yagi
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Barbara L Smith
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
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23
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Tang R, Coopey SB, Merrill AL, Rai U, Specht MC, Gadd MA, Colwell AS, Austen WG, Brachtel EF, Smith BL. Positive Nipple Margins in Nipple-Sparing Mastectomies: Rates, Management, and Oncologic Safety. J Am Coll Surg 2016; 222:1149-55. [DOI: 10.1016/j.jamcollsurg.2016.02.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 11/15/2022]
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Abstract
We present some clinical advice to drive the decision process in performing conservative mastectomies. Several factors are taken into consideration to indicate these techniques. First of all, we need to identify patients who need a mastectomy due to the extension of the disease. In this case we suggest assessing patients anthropometric characteristics (breast volume-ptosis), and personal preferences regarding the extension of surgical treatment. Small, medium size, without ptosis or with moderate ptosis can be better served by standard nipple-sparing mastectomy. Large and ptotic breast can be removed and reconstructed performing a skin-reducing mastectomy. Mastectomies cannot replace breast conservation and should be discouraged whenever breast-conserving surgery can be performed with good results. However, in some selected cases, and especially in patients with small breast, conservative mastectomies with contralateral reshape can yield favourable results.
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Affiliation(s)
- Giuseppe Catanuto
- 1 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 2 Department of Clinical Medicine and Surgery. University of Naples "Federico II" Via S. Pansini 5, 80131 Naples, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122, Milano, Italy
| | - Nicola Rocco
- 1 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 2 Department of Clinical Medicine and Surgery. University of Naples "Federico II" Via S. Pansini 5, 80131 Naples, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122, Milano, Italy
| | - Maurizio Bruno Nava
- 1 Multidisciplinary Breast Unit, Azienda Ospedaliera Cannizzaro, Via Messina 829, 95126 Catania, Italy ; 2 Department of Clinical Medicine and Surgery. University of Naples "Federico II" Via S. Pansini 5, 80131 Naples, Italy ; 3 Scuola di Oncologia Chirurgica Ricostruttiva, Via Besana 4, 20122, Milano, Italy
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25
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Abstract
Knowledge of the anatomy of the nipple and breast skin is fundamental to any surgeon practicing conservative mastectomies. In this paper, the relevant clinical anatomy will be described, mainly focusing on the anatomy of the "oncoplastic plane", the ducts and the vasculature. We will also cover more briefly the nerve supply and the arrangement of smooth muscle of the nipple. Finally the lymphatic drainage of the nipple and areola will be described. An appreciation of the relevant anatomy, together with meticulous surgical technique may minimise local recurrence and ischaemic complications.
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26
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Abstract
Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forlì. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.
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Affiliation(s)
- Camilla Rossi
- Breast Surgery Unit, G.B. Morgagni-Pierantoni Hospital, AUSL della Romagna sede di Forlì (FC), Via Carlo Forlanini, 34. 47100 Forlì, Italy
| | - Matteo Mingozzi
- Breast Surgery Unit, G.B. Morgagni-Pierantoni Hospital, AUSL della Romagna sede di Forlì (FC), Via Carlo Forlanini, 34. 47100 Forlì, Italy
| | - Annalisa Curcio
- Breast Surgery Unit, G.B. Morgagni-Pierantoni Hospital, AUSL della Romagna sede di Forlì (FC), Via Carlo Forlanini, 34. 47100 Forlì, Italy
| | - Federico Buggi
- Breast Surgery Unit, G.B. Morgagni-Pierantoni Hospital, AUSL della Romagna sede di Forlì (FC), Via Carlo Forlanini, 34. 47100 Forlì, Italy
| | - Secondo Folli
- Breast Surgery Unit, G.B. Morgagni-Pierantoni Hospital, AUSL della Romagna sede di Forlì (FC), Via Carlo Forlanini, 34. 47100 Forlì, Italy
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27
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Dua MM, Bertoni DM, Nguyen D, Meyer S, Gurtner GC, Wapnir IL. Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland Surg 2015; 4:497-505. [PMID: 26645004 DOI: 10.3978/j.issn.2227-684x.2015.04.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.
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Affiliation(s)
- Monica M Dua
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Danielle M Bertoni
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Dung Nguyen
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Shannon Meyer
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Geoffrey C Gurtner
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Irene L Wapnir
- 1 Department of Surgery/Section of Surgical Oncology, 2 Division of Plastic Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
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Mori H, Uemura N, Okazaki M, Nakagawa T, Sato T. Nipple malposition after nipple-sparing mastectomy and expander–implant reconstruction. Breast Cancer 2015; 23:740-4. [DOI: 10.1007/s12282-015-0633-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
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29
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Folli S, Mingozzi M, Curcio A, Buggi F, Rossi C. Nipple-Sparing Mastectomy: An Alternative Technique for Large Ptotic Breasts. J Am Coll Surg 2015; 220:e65-9. [DOI: 10.1016/j.jamcollsurg.2015.01.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 01/03/2015] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
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30
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Carlson GW, Chu CK, Moyer HR, Duggal C, Losken A. Predictors of nipple ischemia after nipple sparing mastectomy. Breast J 2013; 20:69-73. [PMID: 24224902 DOI: 10.1111/tbj.12208] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nipple sparing mastectomy (NSM) has become an accepted approach in selected cases of breast cancer and prophylactic mastectomy. Various surgical techniques have been described and nipple ischemia has been a common complication. Potential risk factors for nipple ischemia after NSM are examined. To examine predisposing factors for nipple ischemia after NSM. Prospective evaluation of 71 consecutive NSM in 45 patients from 2009 to 2011 was performed. There were 40 mastectomies for cancer (56.3%), and 31 (43.7%) prophylactic mastectomies. In cases of cancer, the ducts were excised from the undersurface of the nipple. Reconstructive methods included: expander 58, latissimus flap/expander 2, implant 10, and free TRAM flap 1. Various patient and technical factors were examined for impact on nipple ischemia. Partial nipple necrosis occurred in 20 cases (28.2%). Nineteen cases healed uneventfully and one required secondary nipple reconstruction. Operations for cancer (OR 10.54, CI 1.88-59.04, p = 0.007) and periareolar incisions (OR 9.69, CI 1.57-59.77, p = 0.014) predisposed to nipple ischemia. Periareolar incisions and dissection of the nipple ducts for cancer have a higher risk of nipple necrosis after NSM.
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Affiliation(s)
- Grant W Carlson
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia
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31
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Kato H, Nakagami G, Iwahira Y, Otani R, Nagase T, Iizaka S, Tamai N, Matsuyama Y, Sanada H. Risk Factors and Risk Scoring Tool for Infection during Tissue Expansion in Tissue Expander and Implant Breast Reconstruction. Breast J 2013; 19:618-26. [DOI: 10.1111/tbj.12175] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Hirofumi Kato
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | | | | | - Takashi Nagase
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Shinji Iizaka
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Nao Tamai
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Yutaka Matsuyama
- Department of Biostatistics; School of Public Health; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management; Division of Health Sciences and Nursing; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
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32
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Coopey SB, Tang R, Lei L, Freer PE, Kansal K, Colwell AS, Gadd MA, Specht MC, Austen WG, Smith BL. Increasing Eligibility for Nipple-Sparing Mastectomy. Ann Surg Oncol 2013; 20:3218-22. [DOI: 10.1245/s10434-013-3152-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Indexed: 11/18/2022]
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33
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Stolier AJ, Levine EA. Reducing the Risk of Nipple Necrosis: Technical Observations in 340 Nipple-sparing Mastectomies. Breast J 2013; 19:173-9. [DOI: 10.1111/tbj.12078] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alan J. Stolier
- Department of Surgery; Tulane University; New Orleans; Louisiana
| | - Edward A. Levine
- Department of Surgery; Wake Forest University; Winston-Salem; North Carolina
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Folli S, Curcio A, Buggi F, Mingozzi M, Lelli D, Barbieri C, Asioli S, Nava MB, Falcini F. Improved sub-areolar breast tissue removal in nipple-sparing mastectomy using hydrodissection. Breast 2012; 21:190-3. [DOI: 10.1016/j.breast.2011.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 07/06/2011] [Accepted: 09/14/2011] [Indexed: 11/17/2022] Open
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Issues related to advances and controversies in breast cancer management: A multicultural experience. Int J Surg 2012; 10:429-35. [DOI: 10.1016/j.ijsu.2012.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/22/2012] [Accepted: 07/22/2012] [Indexed: 01/09/2023]
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Reynolds C, Davidson JA, Lindor NM, Glazebrook KN, Jakub JW, Degnim AC, Sandhu NP, Walsh MF, Hartmann LC, Boughey JC. Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved? Ann Surg Oncol 2011; 18:3102-9. [PMID: 21947588 DOI: 10.1245/s10434-011-1908-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of nipple-sparing mastectomy (NSM) is increasing. We sought to look at the role of NSM in BRCA mutation carriers. METHODS Tissue from women with a BRCA1 or BRCA2 mutation who underwent mastectomy between March 1987 and June 2009 at a single institution was reviewed. The entire nipple-areolar complex (NAC) was excised and histologically evaluated. The presence of terminal duct lobular units (TDLUs) and premalignant or malignant lesions in the NAC was noted. RESULTS Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct. CONCLUSIONS The probability of nipple involvement by premalignant or malignant lesions in the NAC of BRCA mutation carriers is low at time of prophylactic mastectomy, but higher (10%) in women undergoing therapeutic mastectomy. NSM may be appropriate and oncologically safe for selected women with BRCA mutations. However, 24% of NACs contained TDLUs, with only 8% found in the nipple papilla; the significance of this for long-term risk is unknown.
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Affiliation(s)
- Carol Reynolds
- Department of Pathology, Mayo Clinic, Division of Anatomic Pathology, Rochester, MN, USA.
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Mátrai Z, Gulyás G, Tóth L, Sávolt Á, Kunos C, Pesthy P, Bartal A, Kásler M. Role of nipple sparing mastectomy in modern breast surgery. Orv Hetil 2011; 152:1233-49. [DOI: 10.1556/oh.2011.29156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Recently an increasing number of reports of clinical experience have been published on nipple-sparing mastectomy. By the preservation of uninvolved skin and the nipple areola complex, this surgical technique greatly facilitates immediate reconstruction and optimal aesthetic outcome. However, the procedure raises serious oncologic concerns regarding the risk of an occult or a newly formed primary tumor due to parenchyma left behind in the nipple and the retroareola. Despite the ever increasing popularity of the method, there is still no evidence based confirmation to it. According to data from scientific literature on nipple-sparing mastectomy, there is no straightforward consequence to be drawn on oncologic safety; therefore the procedure is not generally considered to be alternative to standard mastectomy. In the indication of risk reduction, justification of the intervention seems to be well supported, and is expected to foster a greater rate of acceptance of surgical prophylaxis in patients with higher risk diseases. The procedure should be carried out possibly in the framework of clinical trials, in well selected patients with suitable preoperative and postoperative examinations, applying precise techniques and adequate patient education, according to international guidelines. Further long-term results are needed to form a substantive expert opinion. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language. Orv. Hetil., 2011, 152, 1233–1249.
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Affiliation(s)
- Zoltán Mátrai
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Gusztáv Gulyás
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | - László Tóth
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Ákos Sávolt
- Országos Onkológiai Intézet Általános és Mellkassebészeti Osztály Budapest Ráth György u. 7–9. 1122
| | - Csaba Kunos
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | - Pál Pesthy
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
| | | | - Miklós Kásler
- Országos Onkológiai Intézet Fej-Nyak, Állcsont- és Rekonstrukciós Sebészet, Onkológiai Helyreállító Plasztikai Sebészet és Lézersebészeti Osztály Budapest
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Boukerrou M, Dahan Saal J, Laurent T, Barau G, Clough K. [Nipple sparing mastectomy: an update]. ACTA ACUST UNITED AC 2010; 38:600-6. [PMID: 20870442 DOI: 10.1016/j.gyobfe.2010.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 04/26/2010] [Indexed: 11/28/2022]
Abstract
In order to decrease the psychological impact and the mutilating feeling of surgical treatments of the breast cancer when the mastectomy is indicated, authors described and propose the nipple sparing mastectomy (NSM). The only opposable criticism would be the increase of recurrence rate. The study of the recent literature allows us to make a inventory of fixtures concerning this evolution of the surgical practices whether on a technical, oncological, plastic or psychological plan. This technique is not validated in France and adjuvent therapies as the radiotherapy of the nipple are not validated yet. It seems that the NSM is a safe practice from the carcinologic point of view, while having a positive psychological impact in terms of disease and treatment acceptance. The technique seems possible after an information and selection of the patients and with a respect for technical rules (frozen section, peroperative evaluation of the nipple vitality).
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Affiliation(s)
- M Boukerrou
- Service de Gynécologie et Obstétrique, Pôle Femme-Mère-Enfant, Groupe Hospitalier Sud-Réunion, Centre Hospitalier Régional, BP 350, 97448 Saint-Pierre, La Réunion.
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Radovanovic Z, Radovanovic D, Golubovic A, Ivkovic-Kapicl T, Bokorov B, Mandic A. Early Complications after Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Silicone Prosthesis: Results of 214 Procedures. Scand J Surg 2010; 99:115-8. [DOI: 10.1177/145749691009900302] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: Breast reconstruction with silicone prosthesis following nipple-sparing mastectomy has become widely accepted as a reconstruction option in women requiring mastectomy for cancer. The purpose of this study was to evaluate the incidence and some factors influencing early local complications in patients undergoing NSM with immediate implant reconstruction. Material and Methods: Prospective study was performed on a consecutive series of 214 breast reconstructions in 205 patients. All complications during the six weeks after surgery were recorded. 42 prostheses were implanted after neoadjuvant chemotherapy, 27 patients previously had radiotherapy due to breast conserving surgery and in all other cases surgery was the primary treatment for cancer. Results: The overall six-week complication rate was 16% (35) and included: major skin flap necrosis (4%, 9 procedures), minor skin necrosis (3%, 7), major infection (2%, 5), minor infection (3%, 7), prolonged seroma formation (3%, 6), haematoma (1%, 2) and epidermolysis (1%, 2). In 6% (12) reconstruction procedures explantation of prosthesis was done. Neoadjuvant chemotherapy and radiotherapy were not associated with higher rate of complications. Conclusion: Nipple-sparing mastectomy with immediate implant reconstruction has acceptable morbidity rate in the hand of experienced oncoplastic surgeon and therefore should be considered as treatment option to women requiring mastectomy.
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Affiliation(s)
- Z. Radovanovic
- Oncology Institute of Vojvodina, Sremska Kamenica, Novi Sad, Serbia
| | - D. Radovanovic
- Oncology Institute of Vojvodina, Sremska Kamenica, Novi Sad, Serbia
| | - A. Golubovic
- Oncology Institute of Vojvodina, Sremska Kamenica, Novi Sad, Serbia
| | | | - B. Bokorov
- Oncology Institute of Vojvodina, Sremska Kamenica, Novi Sad, Serbia
| | - A. Mandic
- Oncology Institute of Vojvodina, Sremska Kamenica, Novi Sad, Serbia
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Acea Nebril B. ["Scarless" surgery in the treatment of breast cancer]. Cir Esp 2009; 87:210-7. [PMID: 19896646 DOI: 10.1016/j.ciresp.2009.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 09/14/2009] [Accepted: 09/16/2009] [Indexed: 11/18/2022]
Abstract
So-called "scarless" surgery in the treatment of breast cancer consists of a group of procedures with a double aim: local control of the oncological process and maintaining the body image of the woman by making incisions that will not be visible. This article describes four approach routes for scarless surgery (periareolar, axillary, submammary, lateral chest) in different contexts of the oncological breast disease. The application of these incisions in the conservative treatment of breast cancer requires making a wide subcutaneous dissection over the tumour location, and a local reconstruction with adjacent breast tissue, so as not to deform the breast contour, as well as moving the nipple with its areola, thus avoiding the surgical modification of the other breast to maintain symmetry between both. We describe the use of hidden incisions to perform mastectomies that try to conserve as much skin as possible, together with the nipple, as well the dissection, with the aid of an endoscope of the latissimus dorsi muscle, in the immediate breast reconstruction.
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Affiliation(s)
- Benigno Acea Nebril
- Servicio de Cirugía General A, Complejo Hospitalario Universitario A Coruña, A Coruña, España.
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Garcia-Etienne CA, Cody Iii HS, Disa JJ, Cordeiro P, Sacchini V. Nipple-Sparing Mastectomy: Initial Experience at the Memorial Sloan-Kettering Cancer Center and a Comprehensive Review of Literature. Breast J 2009; 15:440-9. [PMID: 19496781 DOI: 10.1111/j.1524-4741.2009.00758.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Carlos A Garcia-Etienne
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York NY 10021, USA
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Voltura AM, Tsangaris TN, Rosson GD, Jacobs LK, Flores JI, Singh NK, Argani P, Balch CM. Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol 2008; 15:3396-401. [PMID: 18923874 DOI: 10.1245/s10434-008-0102-0] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 06/27/2008] [Accepted: 06/28/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Retrospective studies have shown that occult nipple-areolar complex (NAC) involvement in breast cancer is low, occurring in 6-10% of women undergoing skin-sparing mastectomy (SSM). The cosmetic result and high patient satisfaction of nipple-sparing mastectomy (NSM) has prompted further evaluation of the oncologic safety of this procedure. METHODS We conducted a retrospective chart review of 36 self-selected patients who underwent 51 NSM procedures between 2002 and 2007. Criterion for patient selection was no clinical evidence of nipple-areolar tumor involvement. All patients had the base of the NAC evaluated for occult tumor by permanent histologic section assessment. We also evaluated tumor size, location, axillary node status, recurrence rate, and cosmetic result. RESULTS Malignant NAC involvement was found in 2 of 34 NSM (5.9%) completed for cancer which prompted subsequent removal of the NAC. Of the 51 NSM, 17 were for prophylaxis, 10 for ductal carcinoma in situ (DCIS), and 24 for invasive cancer. The average tumor size was 2.8 cm for invasive cancer and 2.5 cm for DCIS. Nine patients had positive axillary nodes. Overall, 94% of the tumors were located peripherally in the breast. After mean follow-up of 18 months, only two patients (5.9%) had local recurrence. CONCLUSION Using careful patient selection and careful pathological evaluation of the subareolar breast tissue at surgery, NSM can be an oncologically safe procedure in patients where this is important to their quality of life. A prospective study based on focused selection criteria and long-term follow-up is currently in progress.
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Affiliation(s)
- Anna M Voltura
- Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
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Chung AP, Sacchini V. Nipple-sparing mastectomy: where are we now? Surg Oncol 2008; 17:261-6. [PMID: 18456492 DOI: 10.1016/j.suronc.2008.03.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Accepted: 03/07/2008] [Indexed: 01/19/2023]
Abstract
Surgical treatment of breast cancer has evolved from radical mastectomy with routine removal of the nipple-areolar complex (NAC) to breast conservative therapy with preservation of the breast and NAC. When breast conservation is not appropriate or the patient desires mastectomy for risk reduction, conventional therapy still consists of mastectomy with removal of the NAC, followed by reconstruction. Rising interest in improved cosmesis has led to the introduction of the skin-sparing and nipple-sparing mastectomy (NSM) as potential alternatives to mastectomy. There has been much controversy regarding the oncologic safety of these procedures, and the NSM has also introduced a set of complications, such as nipple and areolar necrosis, that are not a concern with total mastectomy. From our review of the literature, we feel that NSM may be a viable option in the appropriate setting, and that its risks and complications are acceptable when compared to the traditional surgical treatment of breast cancer.
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Affiliation(s)
- Alice P Chung
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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