1
|
Sae-Lim C, Lai HW, Lin SL, Huang HI, Chen ST, Chen DR. Is minimal-accessed (endoscopic- or robotic-assisted) nipple-sparing mastectomy contraindicated for large breasts? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108030. [PMID: 38402736 DOI: 10.1016/j.ejso.2024.108030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND In the developmental stage of minimal-accessed nipple-sparing mastectomy (MA-NSM), selecting patients with small to medium-sized breasts was common for better cosmetic outcomes and oncological safety. However, the suitability of MA-NSM for large, ptotic breasts remained uncertain. This retrospective study aim to assess MA-NSM outcomes in patients with large breasts. MATERIALS AND METHODS This retrospective study included patients receiving conventional NSM (C-NSM) and MA-NSM from January 2011 to September 2022, at a single institution. We analyzed perioperative parameters and clinical outcomes based on breast specimen size, classified as small (≤300 g), medium (>300-450 g), large (>450-600 g), and very large (>600 g). RESULTS A total of 728 patients was enrolled. C-NSM was performed in 51% (371/728) of cases, while MA-NSM was done in 49% (357/728). The overall complication rate of MA-NSM was comparable to C-NSM (p = 0.573), but severe complications (Clavien-Dindo, CD III) was significantly reported more following C-NSM, regardless of breast size. During a median follow-up of 52 months, no significant difference in oncological outcomes was observed. Comparing MA-NSM and C-NSM outcomes in large-very large breasts (>450 g), MA-NSM demonstrated significantly less blood loss (p = 0.036) and lower incidence of severe complications (CD ≥ III) compared to C-NSM (p = 0.002). CONCLUSION MA-NSM is feasible for large breasts and offers benefits by reducing blood loss and decreasing the incidence of severe complications (CD ≥ III) in this patient group.
Collapse
Affiliation(s)
- Chayanee Sae-Lim
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Hung-Wen Lai
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan; Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan; Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan; Kaohsiung Medical University, Kaohsiung, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shih-Lung Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan.
| | - Hsin-I Huang
- Department of Information Management, National Sun-Yat-Sen University, Kaohsiung, Taiwan.
| | - Shou-Tung Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| | - Dar-Ren Chen
- Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan.
| |
Collapse
|
2
|
Lai HW, Lee YY, Chen ST, Liao CY, Tsai TL, Chen DR, Lai YC, Kao WP, Wu WP. Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features. World J Surg Oncol 2023; 21:23. [PMID: 36694205 PMCID: PMC9875411 DOI: 10.1186/s12957-023-02898-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM). METHODS We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap. RESULTS A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel. CONCLUSION Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.
Collapse
Affiliation(s)
- Hung-Wen Lai
- grid.413814.b0000 0004 0572 7372Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, Changhua, Taiwan ,grid.413814.b0000 0004 0572 7372Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan ,grid.413814.b0000 0004 0572 7372Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan ,grid.413814.b0000 0004 0572 7372Minimal Invasive Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan ,grid.412019.f0000 0000 9476 5696Kaohsiung Medical University, Kaohsiung, Taiwan ,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan ,grid.411641.70000 0004 0532 2041School of Medicine, Chung Shan Medical University, Taichung, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Yuan Lee
- grid.254145.30000 0001 0083 6092Department of Public Health, China Medical University, Taichung, Taiwan
| | - Shou-Tung Chen
- grid.413814.b0000 0004 0572 7372Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan ,grid.413814.b0000 0004 0572 7372Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chiung-Ying Liao
- grid.413814.b0000 0004 0572 7372Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Tsung-Lin Tsai
- grid.413814.b0000 0004 0572 7372Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan ,grid.411641.70000 0004 0532 2041School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Dar-Ren Chen
- grid.413814.b0000 0004 0572 7372Division of General Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan ,grid.413814.b0000 0004 0572 7372Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Yuan-Chieh Lai
- grid.411641.70000 0004 0532 2041School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wen-Pin Kao
- grid.260539.b0000 0001 2059 7017Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan ,grid.413814.b0000 0004 0572 7372Division of Plastic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, 500 Taiwan
| | - Wen-Pei Wu
- grid.412019.f0000 0000 9476 5696Kaohsiung Medical University, Kaohsiung, Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan ,grid.413814.b0000 0004 0572 7372Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| |
Collapse
|
3
|
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.
Collapse
Affiliation(s)
- S Amir Razavi
- From the Division of Plastic Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | |
Collapse
|
4
|
Huang J, Wang M, Chagpar A. Factors Affecting Total Operating Time in Patients Undergoing Mastectomy With and Without Reconstruction. Am Surg 2020; 87:1107-1111. [PMID: 33307721 DOI: 10.1177/0003134820973372] [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: 11/15/2022]
Abstract
BACKGROUND Operating room (OR) time varies significantly in patients undergoing mastectomy. We sought to determine factors influencing OR time such that more accurate predictions could be made. METHODS Records of patients undergoing mastectomy at our institution between January 2010 and June 2018 were reviewed. Operating Room time was defined as time from incision to dressing. Nonparametric analyses were performed to determine factors associated with OR time. A predictive model using linear regression was created on a training set and evaluated in a separate testing set. RESULTS Our cohort included 1008 female patients who underwent either unilateral or bilateral mastectomy (BM), with or without reconstruction, and with or without concomitant axillary lymph node staging at our institution. The median OR time was 4.67 hours (range; .70-16.35 hours). To create a predictive model, we divided our cohort into a training set of 504 patients and a testing set of 504 patients. Across the training set, body mass index (BMI), BM, nonconventional mastectomies, intraoperative frozen sections, receipt of neoadjuvant chemotherapy, and reconstruction were associated with longer OR times on linear regression. A model generated from these findings on the training set was run on the testing set (Pearson correlation = .743 for predicted vs. actual OR times, P < .001). CONCLUSION A number of preoperative factors such as BMI, unilateral vs. BM, type of mastectomy and reconstruction, use of intraoperative frozen sections, and receipt of neoadjuvant chemotherapy can influence OR times. Accurate predictions can be made using a simple model incorporating these factors.
Collapse
Affiliation(s)
- Julian Huang
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Melinda Wang
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
| | - Anees Chagpar
- Department of Surgery, 12228Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|