Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

Minimal Access vs Conventional Nipple-Sparing Mastectomy

Importance

While nipple-sparing mastectomy (NSM) for breast cancer was only performed using the open method in the past, its frequency using endoscopic and robotic surgical instruments has been increasing rapidly. However, there are limited studies regarding postoperative complications and the benefits and drawbacks of minimal access NSM (M-NSM) compared with conventional NSM (C-NSM).

Objective

To examine the differences in postoperative complications between C-NSM and M-NSM.

Design, Setting, Participants

This was a retrospective multicenter cohort study enrolling 1583 female patients aged 19 years and older with breast cancer who underwent NSM at 21 university hospitals in Korea between January 2018 and December 2020. Those with mastectomy without preserving the nipple-areolar complex (NAC), clinical or pathological malignancy in the NAC, inflammatory breast cancer, breast cancer infiltrating the chest wall or skin, metastatic breast cancer, or insufficient medical records were excluded. Data were analyzed from November 2021 to March 2024.

Exposures

M-NSM or C-NSM.

Main Outcomes and Measures

Clinicopathological factors and postoperative complications within 3 months of surgery were assessed. Statistical analyses, including logistic regression, were used to identify the factors associated with complications.

Results

There were 1356 individuals (mean [SD] age, 45.47 [8.56] years) undergoing C-NSM and 227 (mean [SD] age, 45.41 [7.99] years) undergoing M-NSM (35 endoscopy assisted and 192 robot assisted). There was no significant difference between the 2 groups regarding short- and long-term postoperative complications (<30 days: C-NSM, 465 of 1356 [34.29%] vs M-NSM, 73 of 227 [32.16%]; P = .53; <90 days: C-NSM, 525 of 1356 [38.72%] vs M-NSM, 73 of 227 [32.16%]; P = .06). Nipple-areolar complex necrosis was more common in the long term after C-NSM than M-NSM (C-NSM, 91 of 1356 [6.71%] vs M-NSM, 5 of 227 [2.20%]; P = .04). Wound infection occurred more frequently after M-NSM (C-NSM, 58 of 1356 [4.28%] vs M-NSM, 18 of 227 [7.93%]; P = .03). Postoperative seroma occurred more frequently after C-NSM (C-NSM, 193 of 1356 [14.23%] vs M-NSM, 21 of 227 [9.25%]; P = .04). Mild or severe breast ptosis was a significant risk factor for nipple or areolar necrosis (odds ratio [OR], 4.75; 95% CI, 1.66-13.60; P = .004 and OR, 8.78; 95% CI, 1.88-41.02; P = .006, respectively). Conversely, use of a midaxillary, anterior axillary, or axillary incision was associated with a lower risk of necrosis (OR for other incisions, 32.72; 95% CI, 2.11-508.36; P = .01). Necrosis occurred significantly less often in direct-to-implant breast reconstruction compared to other breast reconstructions (OR, 2.85; 95% CI, 1.11-7.34; P = .03).

Conclusions and Relevance

The similar complication rates between C-NSM and M-NSM demonstrates that both methods were equally safe, allowing the choice to be guided by patient preferences and specific needs.

Bridging the Knowledge Gap: Technical Insights and Recommendations for Breast Reduction Surgery

Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of Prostaglandin E1 on Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

BACKGROUND

Necrosis of a cutaneous flap including the nipple-areola complex is a common complication in immediate implant-based breast reconstruction following nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM). This study aimed to evaluate the efficacy of prostaglandin E1 (PGE1) in reducing such complications.

METHODS

A retrospective analysis of prospectively collected data was conducted at two centers, and the cohort consisted of patients undergoing NSM/SSM followed by immediate reconstruction with a prosthesis. Patients who were randomly allocated to the treatment group were administered daily intravenous PGE1 (10 μg/2 mL) beginning intraoperatively through postoperative day 6. Skin flap complications including nipple/skin necrosis, delayed wound healing, and postoperative wound revision were recorded. Complication rates were compared between the PGE1 and control groups.

RESULTS

A total of 276 breasts in 259 patients were included for analysis (139 breasts in the treatment group and 137 breasts in the control group). There was no difference in patient demographics between the control and treatment groups. Reconstructed breasts receiving PGE1 had significantly lower rates of overall skin complications (21.6% versus 34.3%; P = 0.022) and wound revision (2.9% versus 9.5%; P = 0.025). Among NSM cases, the PGE1 group showed a significantly lower rate of nipple necrosis (15.5% versus 29.4%; P = 0.027). In the multivariate analysis, the use of PGE1 significantly reduced the risk of overall skin flap complications (OR, 0.491; P = 0.018) and wound revision (OR, 0.213; P = 0.018) in NSM/SSM cases, and nipple necrosis (OR, 0.357; P = 0.008) in NSM cases.

CONCLUSION

PGE1 can be effective in reducing risk of mastectomy flap complications in immediate implant-based breast reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Impact of Mastectomy Flap Necrosis on Patient-Reported Quality-of-Life Measures After Nipple-Sparing Mastectomy: A Preliminary Analysis

BACKGROUND

Mastectomy skin flap necrosis (SFN) is common following nipple-sparing mastectomy (NSM), but studies on its quality-of-life (QOL) impact are limited. We examined patient-reported QOL and satisfaction after NSM with/without SFN utilizing the BREAST-Q patient-reported outcome measure (PROM) survey.

PATIENTS AND METHODS

Patients undergoing NSM between April 2018 and July 2021 at our institution were examined; the BREAST-Q PROM was administered preoperatively, and at 6 months and 1 year postoperatively. SFN extent/severity was documented at 2-3 weeks postoperatively; QOL and satisfaction domains were compared between patients with/without SFN.

RESULTS

A total of 573 NSMs in 333 patients were included, and 135 breasts in 82 patients developed SFN (24% superficial, 56% partial thickness, 16% full thickness). Patients with SFN reported significantly lower scores in the satisfaction with breasts (p = 0.032) and psychosocial QOL domains (p = 0.009) at 6 months versus those without SFN, with scores returning to baseline at 1 year in both domains. In the "physical well-being-of-the-chest" domain, there was an overall decline in scores among all patients; however, there were no significant differences at any time point between patients with or without SFN. Sexual well-being scores declined for patients with SFN compared with those without at 6 months and also at 1 year, but this did not reach significance (p = 0.13, p = 0.2, respectively).

CONCLUSIONS

Patients undergoing NSM who developed SFN reported significantly lower satisfaction and psychosocial well-being scores at 6 months, which returned to baseline by 1 year. Physical well-being of the chest significantly declines after NSM regardless of SFN. Future studies with larger sample sizes and longer follow-up are needed to determine SFN's impact on long-term QOL.

A New Convenient Incision Model of the Nipple-Sparing Mastectomy: Lateralized Parabolic Multiplanar Incision

BACKGROUND

In this study, a lateralized parabolic multiplanar incision was defined. It was aimed to reduce necrosis in the nipple-areola complex (NAC) and, in the long run, to prevent the scar from pulling the areola laterally by maintaining healthy skin tissue between the scar and the areola and preserving the natural round appearance of the areola. Moreover, we purposed the scar not to be visible from the anterior view.

METHODS

The study included 243 patients who underwent nipple-sparing mastectomy and immediate implant-based breast reconstruction. The incision was made 4-5 cm away from the lateral border of the NAC. The incision was completed after passing the anterior axillary line by drawing a parabolic curve in superolateral axis.

RESULTS

The mean follow-up period was 24.6 months, and the mean age of the patients was 42.3 years. Full-thickness necrosis of the NAC occurred in 3.6% of breasts. In long-term follow-ups, the incision scar measured an average length of 8.6 cm. None of the patients had lateral displacement of the NAC. The NAC preserved its round appearance, except for 12 breasts that had full-thickness NAC necrosis. Ten breasts had an unnatural breast appearance.

CONCLUSION

The lateralized parabolic multiplanar incision is an ideal incision model for nipple-sparing mastectomy, as it allows for the exposure and reconstruction of all breast quadrants. We maintain areolar circulation; there are no visible scars when viewed anteriorly. Furthermore, it prevents lateral displacement of the NAC, ensuring that the natural round form of the NAC is not distorted.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk Factors for Skin Flap and Nipple-Areolar Necrosis in Patients Undergoing Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Reconstruction

INTRODUCTION

Nipple-sparing mastectomy (NSM) with deep inferior epigastric perforator (DIEP) flap reconstruction is a surgical option for select patients with or at risk of breast cancer. However, post-operative skin flap and nipple-areolar complex (NAC) necrosis remain common complications. This study aimed to identify factors associated with necrosis in patients undergoing NSM with DIEP reconstruction.

METHODS

A retrospective cohort study was performed from 2015 to 2023. 74 variables were analyzed in patients undergoing NSM with DIEP. Patients were stratified into 3 groups based on post-operative skin/NAC necrosis: none, partial thickness, and full thickness. Comparative and descriptive statistics were performed via t-tests, ANOVA, and chi-squared tests.

RESULTS

34 women with 31 breast cancers met inclusion. 44% experienced necrosis: 15% partial thickness and 29% full thickness. The majority were white (85.3%) with mean age of 50 years (SD = 9.11). In patients with immediate DIEP reconstruction, hypoperfused areas identified by SPY angiography increased risk of necrosis (P = .012). Approximately 50% of both partial thickness and full thickness necrosis patients had concerns on SPY angiography. Former smokers in the full thickness necrosis group had more pack years than those without necrosis (9 vs .65 pack years, P = .035).

CONCLUSION

In patients receiving NSM with DIEP flap reconstruction, those with hypoperfusion on SPY angiography and longer smoking history had higher necrosis rates. This supports the continued used of SPY angiography and the role of pre-operative counseling in former smokers with increased pack years on their risk of necrosis and the role of preventative measures in the perioperative setting.

Impact of mastectomy flap necrosis on prepectoral reconstructive outcomes

INTRODUCTION

As reconstructive surgeons have increasingly transitioned to the prepectoral plane for prosthetic breast reconstruction, the implications of mastectomy skin flap necrosis have become more concerning. Our goal was to evaluate the effect of skin flap necrosis on reconstructive outcomes in patients undergoing immediate prepectoral breast reconstruction.

METHODS

A retrospective review was conducted of patients undergoing immediate two-stage prepectoral reconstruction at a single center with at least 3 months follow-up. Postoperative complications, reconstructive outcome, and time to final implant were compared between patients with and without mastectomy skin necrosis.

RESULTS

A total of 301 patients underwent 509 prepectoral breast reconstructions. Forty-four patients (14.6%) experienced postoperative mastectomy skin flap necrosis. Demographic and reconstructive characteristics were similar between the necrosis and no necrosis cohorts. Patients with skin necrosis were more likely to undergo reoperation after tissue expander (64% vs 19%, p < 0.01) and undergo expander replacement (13.6% vs 3.5%, p = 0.02). However, rates of reconstructive failure (6.8% vs 6.2%), major infection (9.1% vs 9.0%), and minor infection (13.6% vs 17.5%) after expander placement were statistically similar. Patients with skin necrosis trended toward longer time before final implant placement, although the difference was not statistically significant (6.5 vs 5.0 months, p = 0.08). There was no difference in complication rates between the necrosis and no necrosis cohort after final implant placement. There was a higher rate of revision surgery after implant placement in the necrosis cohort (12.5% vs 4.1%, p = 0.047).

CONCLUSIONS

Mastectomy skin flap necrosis is a concerning postoperative event, particularly in patients with prepectoral prostheses. We observed that patients with skin necrosis experience higher reoperation rates in the expander period, yet have similar infection rates and achieve similar final reconstructive outcomes compared to patients without necrosis.

A novel technique of reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction: medium-term oncological safety outcomes and feasibility of 24-hour discharge for breast cancer patients

BACKGROUND

Due to the short operation time and no need for special instruments, reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) has been rapidly becoming popular in the last three years. However, there has yet to be an evaluation of its oncologic safety or the feasibility of discharging patients within 24 hours.

MATERIALS AND METHODS

In this single-center retrospective cohort study, individuals diagnosed with stage 0-III breast cancer between May 2020 and April 2022 who underwent traditional open mastectomy or R-E-NSM with DIBR were included. Follow-up started on the date of surgery and ended in December 2023. Data, including demographics, tumor characteristics, medium-term oncological outcomes, and postoperative complications, were collected and analyzed. Propensity score matching (PSM) was performed to minimize selection bias.

RESULTS

This study included 1679 patients (median [IQR] age, 50 [44-57] years). Of these, 344 patients underwent R-E-NSM with DIBR (RE-R group), and 1335 patients underwent traditional open mastectomy (TOM group). The median [IQR] follow-up time was 30 [24-36] months (29 [23-33] months in the RE-R group and 30 [24-36] months in the TOM group). Regarding before or after PSM, the P value of local recurrence-free survival (LRFS, 0.910 and 0.450), regional recurrence-free survival (RRFS, 0.780 and 0.620), distant metastasis-free survival (DMFS, 0.061 and 0.130), overall survival (OS, 0.260 and 0.620), disease-free survival (DFS, 0.120 and 0.330) were not significantly different between the RE-R group and the TOM group. The 3y-LRFS and 3y-DFS rates were 99.0% and 97.1% for the RE-R group and 99.5% and 95.3% for the TOM group, respectively. The rates of any complications and major complications were not significantly different between the RE-R patients who were discharged within 24 hours and the RE-R patients who were not discharged within 24 hours (P=0.290, P=0.665, respectively) or the TOM patients who were discharged within 24 hours (P =0.133, P=0.136, respectively).

CONCLUSIONS

R-E-NSM with DIBR is an innovative oncologic surgical procedure that not only improves cosmetic outcomes but also ensures reliable oncologic safety and fewer complications, enabling patients to be safely discharged within 24 hours. A long-term prospective multicenter assessment will be supporting.

Inframammary versus Periareolar Incision: A Comparison of Early Complications in Nipple-sparing Mastectomy

Background

Nipple-sparing mastectomy (NSM), either used therapeutically or prophylactically, may yield more complications than conventional mastectomy. The incision may affect aesthetic outcome and complication rates, with periareolar incisions being associated with nipple-areolar complex (NAC) necrosis.

Methods

Early complications were compared between NSM performed in 2015-2022 using inframammary fold (IMF) or periareolar incisions.

Results

Overall, 180 procedures in 152 patients (bilateral NSM = 28) were included (IMF = 104; periareolar = 76). Mean age (47 versus 43.9 years; P < 0.038), mastectomy weight (312.7 versus 246.8 grams; P < 0.001), implant volume (447.5 versus 409.0 mL; P = 0.002), and use of tissue expanders (68.4% versus 50.0%; P = 0.013) were all greater with periareolar incisions. Prepectoral reconstruction was more common with IMF (18.3% versus 3.9%; P = 0.004). Forty-three complications (23.9%) were recorded (periareolar n = 27, 35%; IMF n = 16, 15.3%; P = 0.0002). NAC necrosis accounted for 17 complications (22.4%) in the periareolar group versus nine (8.5%) in the IMF group (P = 0.002). Necrosis was predominantly moderate (n = 6, 8.3% versus n = 1, 1.0%, respectively) (P = 0.014). Unadjusted odds ratios (OR) for complications [3.05; 95% confidence interval (CI): 1.27-7.26] and necrosis (3.04; 95% CI: 1.27-7.27) were higher in the periareolar group. In the multivariate analysis, necrosis was associated with periareolar incisions [adjusted odds ratio (aOR): 2.92; 95% CI: 1.14-7.44]. Prepectoral reconstruction was associated with IMF incisions (aOR: 25.51; 95% CI: 3.53-184.23; P = 0.001) and with body mass index of more than 25-30 (aOR: 37.09; 95% CI: 5.95-231.10; P < 0.001). Therapeutic mastectomies (aOR: 68.56; 95% CI: 2.50-188.36; P = 0.012) and tissue expanders (aOR: 18.36; 95% CI: 1.89-178.44; P = 0.026) were associated with seromas.

Conclusions

Both incisions are viable options; however, the risk of NAC necrosis increased with the periareolar approach. Further research is required.

Intraoperative Examination of Retro-Areolar Margin is not Routinely Necessary During Nipple-Sparing Mastectomy for Cancer

BACKGROUND

Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage.

METHODS

Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting.

RESULTS

Among 162 women operated in the study period, the presence of neoplastic cells within 2 mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1 mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2 mm was associated with radiological tumor-to-nipple distance less than or equal to 1 cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2 mm were not different.

CONCLUSIONS

IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.

Mastectomy with Reconstruction Including Robotic Endoscopic Surgery (MARRES): a prospective cohort study of the Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) and Korean Breast Cancer Study Group (KBCSG)

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes.

METHODS

MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2, TP53, PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000.

DISCUSSION

This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.

Strategies to avoid mastectomy skin-flap necrosis during nipple-sparing mastectomy

BACKGROUND

Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data examining modifiable intraoperative factors that contribute to skin-flap necrosis after nipple-sparing mastectomy.

METHODS

Data on consecutive patients undergoing nipple-sparing mastectomy between April 2018 and December 2020 were recorded prospectively. Relevant intraoperative variables were documented by both breast and plastic surgeons at the time of surgery. The presence and extent of nipple and/or skin-flap necrosis was documented at the first postoperative visit. Necrosis treatment and outcome was documented at 8-10 weeks after surgery. The association of clinical and intraoperative variables with nipple and skin-flap necrosis was analysed, and significant variables were included in a multivariable logistic regression analysis with backward selection.

RESULTS

Some 299 patients underwent 515 nipple-sparing mastectomies (54.8 per cent (282 of 515) prophylactic, 45.2 per cent therapeutic). Overall, 23.3 per cent of breasts (120 of 515) developed nipple or skin-flap necrosis; 45.8 per cent of these (55 of 120) had nipple necrosis only. Among 120 breasts with necrosis, 22.5 per cent had superficial, 60.8 per cent had partial, and 16.7 per cent had full-thickness necrosis. On multivariable logistic regression analysis, significant modifiable intraoperative predictors of necrosis included sacrificing the second intercostal perforator (P = 0.006), greater tissue expander fill volume (P < 0.001), and non-lateral inframammary fold incision placement (P = 0.003).

CONCLUSION

Modifiable intraoperative factors that may decrease the likelihood of necrosis after nipple-sparing mastectomy include incision placement in the lateral inframammary fold, preserving the second intercostal perforating vessel, and minimizing tissue expander fill volume.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review

PURPOSE

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.

METHODS

We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.

RESULTS

Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.

CONCLUSION

ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Salvage of Nipple-Areolar Complex Ischemia With Dimethyl Sulfoxide: A Case Series

BACKGROUND

Nipple-areolar complex (NAC) necrosis is a known risk of breast surgery, particularly mastectomy. Disruption of the underlying blood supply to the NAC can lead to ischemia and subsequent necrosis. Nitroglycerin paste is currently used to combat NAC ischemia but has limited efficacy and an unfavorable side effect profile. Topical dimethyl sulfoxide (DMSO) has been shown to increase tissue perfusion in microsurgery and various skin flaps, but its role in the treatment and prevention of NAC ischemia has not been reported. Through a prospective case series, this study aims to introduce DMSO as a safe treatment for NAC ischemia after breast surgery.

METHODS

Patients treated by 2 breast surgeons and a single plastic surgeon who underwent nipple-sparing mastectomy or breast reduction and developed NAC ischemia were identified via a prospectively maintained database. Ischemic changes were diagnosed, and treatment to the affected NAC with DMSO was initiated at the conclusion of the procedure, or postoperative day 1 in most cases, and continued 4 times daily until ischemic changes had resolved clinically. Collected demographic, surgical, and outcome variables were analyzed using descriptive statistics.

RESULTS

Eleven patients with a mean age of 47.8 ± 9.5 years (range, 35-61 years) and mean body mass index of 26.0 ± 4.4 kg/m2 (range, 20.7-33.4 kg/m2) were identified. The mean duration of time between surgery and the clinical diagnosis of NAC ischemia was 1.3 ± 2.8 days (range, 0-7 days). The average length of time from DMSO initiation to clinical improvement or resolution of NAC ischemia was 7.5 ± 2.5 days (range, 5-12 days). All patients demonstrated significant improvement or complete resolution of NAC ischemia following serial topical DMSO application.

CONCLUSIONS

This study demonstrates DMSO is a safe treatment for threatened NACs. All patients in this series showed either dramatic improvement or resolution of NAC ischemia after DMSO application, and threatened NACs of all 11 patients were successfully salvaged. These promising results set the basis for ongoing randomized controlled studies to determine the efficacy of DMSO treatment for NAC ischemia.

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

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.

[Techniques and complications of non-genetic risk reducing mastectomies: Guidelines of the National College of French Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

Based on an updated review of the international literature covering the different surgical techniques and complications of risk reducing mastectomies (RRM) in non-genetic context, the Commission of Senology (CS) of the College National des Gynécologues Obstétriciens Français (CNGOF) aimed to establish recommendations on the techniques to be chosen and their implementation.

DESIGN

The CNGOF CS, composed of 24 experts, developed these recommendations. A policy of declaration and monitoring of links of interest was applied throughout the process of making the recommendations. Similarly, the development of these recommendations did not benefit from any funding from a company marketing a health product. The CS adhered to and followed the AGREE II (Advancing guideline development, reporting and evaluation in healthcare) criteria and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making recommendations in the presence of poor quality or insufficient evidence were highlighted.

METHODS

The CS considered 6 questions in 4 thematic areas, focusing on oncologic safety, risk of complications, aesthetic satisfaction and psychological impact, and preoperative modalities.

RESULTS

The application of the GRADE method resulted in 7 recommendations, 6 with a high level of evidence (GRADE 1±) and 1 with a low level of evidence (GRADE 2±).

CONCLUSION

There was significant agreement among the CS members on recommendations for preferred surgical techniques and practical implementation.

Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction

Background

Immediate breast reconstruction following nipple-sparing mastectomy (NSM) is widely used for its cosmetic benefits. Due to the lack of guidelines, the types of incisions in NSM vary and which method is superior remains a debate. In this study, we hypothesized that the periareolar incision has a higher risk of complications, such as nipple-areolar complex (NAC) necrosis, than other incisions.

Methods

A retrospective chart review was conducted and divided into three groups: the periareolar, radial, and lateral incision groups. The reconstruction method and complications of NAC necrosis, wound dehiscence, seroma, hematoma, infection, and reconstruction failure were investigated.

Results

A total of 103 patients (periareolar incision (33%, n = 34), radial incision (39.8%, n = 41), and lateral incision (27.2%, n = 28)) who underwent NSM and immediate breast reconstruction from 2018 to 2020 were included. The reconstruction methods were direct-to-implant, DIEP flap, LD flap, and PAP flap, and there was all of which had no statistically significant difference between the groups regarding the reconstruction method (p=0.257). In terms of complications, there was no significant difference in NAC necrosis (29.4%, 19.5%, and 21.4%, in the periareolar, radial, and lateral groups, respectively; p=0.578), wound dehiscence, seroma or hematoma, infection, and reconstruction failure.

Conclusion

Breast reconstruction following NSM through periareolar incision does not increase the incidence of complications, including NAC necrosis. However, since only Asian patients with low BMI were included, if an appropriate patient group is selected for immediate reconstruction after NSM, reconstruction can be safely performed through the periareolar incision, and good cosmetic results can be obtained.

Impact of Body Composition on Postoperative Outcomes in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction

Nipple-areolar complex (NAC)-related complications are common during nipple-sparing mastectomy (NSM), with obesity as a risk factor. Although the incidence of NAC-related complications after robotic NSM (RNSM) with immediate breast reconstruction (IBR) is lower than that after conventional NSM, it remains one of the most unwanted complications. We aimed to evaluate body composition-based risk factors for NAC-related complications after RNSM with IBR. Data of 92 patients with breast cancer who underwent RNSM with IBR using direct-to-implant or tissue expander from November 2017 to September 2020 were analyzed retrospectively. Risk factors for NAC-related complications were identified with a focus on body composition using preoperative transverse computed tomography at the third lumbar vertebra level. Postoperative complications were assessed for 6 months. The most common complication was NAC ischemia, occurring in 15 patients (16%). Multivariate analysis revealed a low skeletal muscle index/total adipose tissue index (SMI/TATI) ratio as an independent NAC ischemia risk factor. An increase in the SMI/TATI ratio by one decreased the incidence of NAC ischemia by 0.940-fold (p = 0.030). A low SMI/TATI ratio is a risk factor for postoperative NAC ischemia in patients undergoing RNSM with IBR for breast cancer. Preoperative body composition-focused evaluation is more valuable than simple body mass index assessment.

Oncoplastic breast surgery: A guide to good practice

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.

Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study

BACKGROUND

Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage.

METHODS

We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure.

RESULTS

Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group.

CONCLUSIONS

Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

Immediate Reconstruction of Large Ptotic Breasts following Vertical Reduction Pattern Nipple-Sparing Mastectomy

Purpose

Women with large and/or ptotic breasts are generally not considered candidates for nipple-sparing mastectomy because of concerns regarding the high incidence of postoperative complications including ischemic complications. Therefore, we adopted a vertical skin resection technique for nipple-sparing mastectomy, and obtained satisfactory results following immediate autologous breast reconstruction. In this study, we aimed to describe our operative technique and review its outcomes.

Methods

Between January 2010 and March 2017, immediate autologous breast reconstructions were performed in 28 patients with moderate or large ptotic breasts after nipple-sparing mastectomy using the vertical reduction pattern. Grade II ptosis was observed in 12 patients, and 16 patients were classified as having grade III ptosis.

Results

Of the 28 patients, 21 received abdominal free flap reconstruction. In the remaining 7 patients, extended latissimus dorsi flaps were used in conjunction with anatomic implants. The mean weight of the excised breast tissue in the 2 groups was 575 g and 482 g, respectively. Satisfactory esthetic outcomes without major complications were achieved in all patients. Similar vertical reductions or mastopexies in the contralateral breast allowed better postoperative adjustment for symmetry. There was only 1 case of complete nipple necrosis; however, the problem was solved with “skin banking.” No local recurrences or distant metastases were detected at follow-up (mean 18 months, range 4 months to 6 years).

Conclusion

To enhance cosmetic outcomes in patients with large and/or ptotic breasts, the vertical skin resection pattern for nipple-sparing mastectomy can be used to achieve better breast shape while preserving the nipple-areola complex. Moreover, it can improve the esthetic outcome without compromising oncologic safety.

A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

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Mastectomy techniques and reconstruction evolved to improve cosmetic outcomes.

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Different techniques maybe associated with different amount of residual breast tissue.

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More data is needed to estimate who are the patients at risk for residual disease or recurrence.

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Multidisciplinary work needed to individualise treatment for optimal oncological outcomes while maintaining the significant improvements in achieving better cosmesis for these patients.