Nipple sparing mastectomy: can we predict the factors predisposing to necrosis?

Extreme Nipple-Sparing Mastectomy: Feasibility of Nipple Preservation and Immediate Reconstruction in Breasts Weighing Over 600 Grams in a Cohort of 43 Patients

Background: Limited data exist on complication rates in nipple-sparing mastectomy (NSM) in patients with large-volume breasts. Our aim was to evaluate the early complication rates of NSM with immediate reconstruction in a consecutive cohort of patients with large-volume breasts. Methods: After IRB approval, patients treated with prophylactic or therapeutic NSM and immediate reconstruction from January 2020 to June 2022 at our health network were identified. Patients with breast weights > 600 g (the extreme NSM group) were compared to patients with breast weights of 600 g or less (the average-volume NSM group). Results: A total of 184 patients underwent NSM with immediate reconstruction. Forty-three of 184 (23.37%) NSM patients had breast weights > 600 g. Of these, 30 patients had bilateral NSM, for a total of 73 breasts with volumes over 600 g, ranging from 603 to 1658 g. There were significantly more total complications in the extreme NSM compared to average-volume NSM groups (41.86% vs. 21.99%, p=0.009852). When broken down into major and minor complications, the extreme NSM group had significantly more major complications than the average-volume NSM group (27.91% vs. 12.86%, p=0.01072), but no difference in minor complications (13.95% vs. 9.29%, p=0.2205). Overall, one (2.33%) patient in the extreme NSM group had a reconstruction failure, compared to three (2.14%) in the average-volume NSM group. Only two of 43 (4.65%) patients in the extreme NSM group lost their nipples due to total or partial nipple necrosis. Conclusions: NSM with immediate reconstruction was successful in the majority of patients with large-volume breasts. The rate of nipple loss was acceptably low. Women with breast volumes larger than 600 g who are motivated to save their nipples at the time of mastectomy could be offered NSM.

Staged Nipple Delay Procedure Expands Candidacy for Nipple-Sparing Mastectomy

BACKGROUND

Nipple delay (ND) is a staged procedure that improves nipple-areolar complex (NAC) viability in nipple-sparing mastectomy (NSM) patients who are high-risk for NAC or skin-flap necrosis. This study compared postoperative outcomes and risk factors between patients treated with ND-NSM and NSM alone.

METHODS

Patient demographics, risk factors for NAC or skin-flap necrosis, tumor characteristics, and operative outcomes were compared between ND-NSM and NSM groups from 2009 to 2023. Univariate and multivariate analyses were performed to identify significant variables associated with NAC or skin-flap necrosis.

RESULTS

Overall, 71 ND-NSM patients and 537 NSM patients were compared. ND-NSM patients had larger breasts (p < 0.01), body mass index ≥ 30 (p = 0.01), prior breast/chest wall radiation (XRT) [p < 0.01], prior breast operations (p < 0.01), less axillary surgery (p < 0.01), more autologous tissue reconstruction over implant-based reconstruction compared with NSM patients (p = 0.02), and more prophylaxis (p < 0.01). There were no statistically significant differences between groups in regard to infection, skin-flap necrosis, NAC necrosis, seromas, and hematomas. No patients in the ND-NSM group had NAC necrosis and 1 patient had skin-flap necrosis, compared with 17 and 13 patients in the NSM group, respectively (p = 0.24). On univariate analysis, prior XRT was associated with increased risk for skin-flap necrosis (p = 0.02). Multivariate analysis showed XRT was associated with skin-flap necrosis (p = 0.02) and any necrosis (p = 0.01). Breast size was associated with NAC or skin-flap necrosis (p = 0.04).

CONCLUSION

Larger breasts and XRT were risk factors for NAC or skin-flap necrosis; however, despite having more risk factors, ND-NSM patients had very low rates of necrosis. Notably, no nipples were lost. A shared decision should be made with patients regarding the risks and benefits of ND-NSM.

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 .

Updated findings of skin flap thickness and residual breast tissue after mastectomy for breast cancer: a systematic review of the literature

BACKGROUND

There is limited evidence on the ideal retention thickness of skin flap in mastectomy. Residual breast tissue (RBT) after mastectomy still represents an unknown risk for local recurrence or new breast cancer lesions. We made this systematic review to identify the optimal flap after mastectomy with minimal complications and better oncological safety.

METHODS

A systematic review was performed using MEDLINE search in PubMed, Embase, and Cochrane Library with the search terms relevant to skin flap thickness and residual breast tissue in breast cancer patients undergoing mastectomy.

RESULTS

Twenty-one studies were included of which fifteen studies enrolled 3814 patients who received mastectomy, and additional six studies were based on cadavers or breast specimens. Four studies confirmed the presence of the superficial fascial layer (Camper's fascia) which can theoretically be used as an anatomical marker for flap retention during mastectomy. Two other studies confirmed Camper's fascia deficiency to a greater or lesser extent. The flap thickness ranged from 3.8 mm to 23 mm in 2692 patients of 7 studies, which was related to BMI, breast size, and examination modalities. Two retrospective and one prospective studies confirmed flaps exceeding 5 mm could significantly increase postoperative complications. Nine studies including 1122 patients explored the association among flap thickness, RBT, and complications, 3 studies of which confirmed excessive flap thickness could cause a significant increase in RBT, which proved to be a potential risk factor for local recurrence in 3 studies. Flaps beyond 5 mm were also found to significantly increase the chance of local recurrence in 4 studies.

CONCLUSION

Camper's fascia can serve as an ideal demarcation between fat and breast tissue based on most current studies. 5 mm thickness of the flap retention in mastectomy is recommended if Camper's fascia is absent or obscure, through which better cosmetic outcomes and less RBT can be achieved.

Predicting Nipple Necrosis with a "Lights-on" Indocyanine Green Imaging System: A Report of Two Patients

Nipple-areolar complex (NAC) necrosis is a devastating complication in nipple-sparing mastectomies (NSMs) that significantly impacts patient's quality of life. The use of fluorescence angiography for intraoperative assessment of mastectomy skin flap perfusion in NSM has been successfully described and can be utilized to help guide surgical decision-making. Recently, a novel fluorescence-guided surgical imager was developed, OnLume Avata System (OnLume Surgical, Madison, WI), which provides intraoperative evaluation of vascular perfusion in ambient light. In this case report, we describe the use of OnLume fluorescence-guided surgery technology to help aid in clinical decision-making for two breast reconstruction cases with concern for intraoperative nipple hypoperfusion.

Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60.

PATIENTS AND METHODS

A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected.

RESULTS

We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up.

CONCLUSIONS

Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.

Nipple Projection Change in Immediate Breast Reconstruction and Use of an Acellular Dermal Matrix Strut for Maintaining Nipple Projection

BACKGROUND

Nipple-sparing mastectomy (NSM) has gained popularity as more studies have supported its oncologic safety. Although there have been some studies reporting complications including mastectomy flap and nipple necrosis, there have been few reports discussing the change in nipple projection following NSM. This study aimed to analyze the change in nipple projection after NSM and identify risk factors for nipple depression. In addition, the authors present a new method for maintaining nipple projection.

METHODS

Patients who underwent NSM between March of 2017 and December of 2020 at the authors' institute were included in this study. The authors measured the preoperative and postoperative nipple projection height and used a nipple projection ratio (NPR) to compare the change in height. Univariate and multivariate analyses were performed to examine the correlation of variables with the NPR.

RESULTS

A total of 307 patients and 330 breasts were included in this study. There were 13 cases of nipple necrosis. The postoperative nipple height was decreased by 32.8%, which was statistically significant. In multiple linear regression analysis, the use of an acellular dermal matrix strut was positively correlated with the NPR and implant-based reconstruction and postmastectomy radiation therapy were negatively correlated with the NPR.

CONCLUSIONS

The results of this study demonstrated that the reduction in nipple height after NSM was statistically significant. Surgeons need to be aware of these changes following NSM and explain this possibility to patients who have risk factors. The application of an acellular dermal matrix strut should be considered for the prevention of nipple reduction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Topical Nitroglycerin Ointment Reduces Mastectomy Flap Necrosis in Immediate Autologous Breast Reconstruction

BACKGROUND

Mastectomy flap necrosis (MFN) is a common complication of immediate breast reconstruction that greatly affects patient satisfaction and cosmetic outcomes. Topical nitroglycerin ointment, with its low cost and negligible side effects, has been shown to significantly decrease the incidence of MFN in immediate implant-based breast reconstruction, but its utility has not been studied in immediate autologous reconstruction.

METHODS

With institutional review board approval, a prospective cohort study was performed of all consecutive patients undergoing immediate free-flap breast reconstruction by a single reconstructive surgeon at a single institution between February of 2017 and September of 2021. Patients were divided into two cohorts: those who received 30 mg of topical nitroglycerin ointment to each breast at the conclusion of the operation (September of 2019 to September of 2021) and those who did not (February of 2017 to August of 2019). All patients underwent intraoperative SPY angiography, and mastectomy skin flaps were débrided intraoperatively based on imaging. Independent demographic variables were analyzed, and dependent outcome variables included mastectomy skin flap necrosis, headache, and hypotension requiring removal of ointment.

RESULTS

A total of 35 patients (49 breasts) were included in the nitroglycerin cohort and 34 patients (49 breasts) were included in the control group. There was no significant difference in patient demographics, medical comorbidities, or mastectomy weight between cohorts. The rate of MFN decreased from 51% in the control group to 26.5% in the group that received nitroglycerin ointment ( P = 0.013). There were no documented adverse events associated with nitroglycerin use.

CONCLUSION

Topical nitroglycerin ointment significantly decreases the rate of MFN in patients undergoing immediate autologous breast reconstruction without significant adverse effects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Implant selection in natural and stable direct-to-implant reconstruction with ten steps at nipple-sparing mastectomy

Direct-to-implant reconstruction is one of the breast repair techniques after mastectomy. Implant selection is critical in the short- and long-term success of direct-to-implant reconstruction after nipple-sparing mastectomy. In this study we developed a 10-step algorithm that we use before and during surgery. We aimed to obtain natural and stable breast reconstruction with this algorithm. In addition, we also aimed to evaluate which implants were selected using this algorithm and their short- and long-term outcomes. This retrospective study included 218 patients aged 27 to 60 years who underwent mastectomy and direct-to-implant reconstruction between November 2018 and December 2021. The patients were assigned into 4 groups according to amount of breast tissue removed. We developed a 10-step algorithm and these included: breast base, amount of breast tissue removed, evaluation of mastectomy skin flap, breast projection, ptosis, unilateral/bilateral reconstruction, chest wall deformity, patient's request, comorbid conditions and stabilization and arrangement of novel sulcus. The evaluation was made when the patient's photographs were taken at least 1 year after the surgery. The highest number of patients was recorded in group 3; in addition, mean age was also highest in group 3. The lowest number of patients was recorded in group 4. The body mass index showed a progressive increase from group 1 to group 4. Medium height moderate profile prosthesis was used in 81.7% while medium height moderate plus profile prosthesis was used in 18.3% of breasts included. We used larger prosthesis up to 58.1% when compared to the tissue removed in group 1 while we used smaller prosthesis by 25.6% in group 4. In the anterior view, the medial and lateral arch of the lower pole of the breast was obtained in all patients. Obvious asymmetry developed in 4 patients. In lateral and oblique views, upper and lower pole natural breast images were obtained in all patients, except for 5 patients. There was no sulcus inferior displacement in any patient. Implant extrusion did not occur in any patient. This algorithm is an easy to use and effective method to obtain a stable and natural breast image in the long-term.

Patient satisfaction after nipple-sparing mastectomy with intraoperative radiotherapy and breast reconstruction for breast cancer

INTRODUCTION

The use of nipple-sparing mastectomy (NSM) combined with breast reconstruction is increasing in breast cancer surgeries despite its controversial safety profile. To reduce the recurrence rate of tumors in the nipple-areola complex (NAC), we used intraoperative radiotherapy (IORT). The purpose of this study was to explore patients' feedback on this novel treatment strategy.

PATIENTS AND METHODS

From January 2014 to May 2018, eligible patients with breast cancer were enrolled in this study and separated into 2 groups. Patients in the NSM group underwent IORT to the NAC flap, and patients in the skin-sparing mastectomy (SSM) group underwent SSM and breast reconstruction. The postoperative satisfaction was collected and assessed using the Breast-Q reconstruction questionnaire and a standardized questionnaire; this was compared between the 2 groups.

RESULTS

There were 46 patients (52 NSMs) in the NSM group and 20 patients (22 SSMs) in the SSM group. The breast-Q scores were higher in the NSM group than the SSM group, with trends for a 'higher satisfaction with breasts' (67.39 ± 20.59 vs. 55.00 ± 19.33; p = 0.026) and 'higher sexual well-being' (61.74 ± 22.24 vs. 49.50 ± 20.12; p = 0.039). All the patients recognized the importance of nipple preservation. Thirty-seven women (80.40%) were satisfied or very satisfied with the appearance and shape of the NAC in the NSM group, while 38/46 women (82.60%) were very unsatisfied or unsatisfied with the sensitivity of the nipples.

CONCLUSIONS

The Breast-Q scores showed great satisfaction with breasts and sexual well-being in the NSM group. However, more effort should be made in improving postoperative NAC sensitivity.

Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy

BACKGROUND

Surgical delay (SD) techniques, performed before the nipple sparing mastectomy (NSM), are procedures conceived to improve the blood supply to the nipple-areola complex (NAC) in order to overcome the ischemic risk. The aim of the study is reporting our experience with SD of the NAC in the setting of NSM, identify the rate of nipple and skin necrosis and other complications and to evaluate patient satisfaction with cosmetic outcome.

PATIENTS AND METHODS

A retrospective review of female patients, who underwent NSM and breast reconstruction between the July 2014 and the July 2019, was performed at the Breast Unit of San Giovanni-Addolorata Hospital in Rome. Eighty-nine NSM after SD procedure were performed in 66 patients. In all cases immediate breast reconstruction was performed with a direct to implant technique and polyurethane implants in prepectoral plan were used in all reconstructions.

RESULTS

We registered only 1 case of total NAC necrosis and 3 skin flap necrosis. Furthermore, patient satisfaction with breast reconstruction resulted excellent or good in 23 cases and good in 36 cases; the external plastic surgeon considered the breast reconstruction excellent or good in 63 cases.

CONCLUSION

We support the thesis that SD techniques may expand indications for NAC sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications. Microabstract This is the largest single center series on surgical delay of nipple areola complex providing interesting data on follow-up and complication rates and we support the thesis that surgical delay techniques may expand indications for nipple-areola complex sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.

Using Clinical Measurements to Predict Breast Skin Necrosis: A Quantitative Analysis

BACKGROUND

Breast skin necrosis can lead to poor healing, reoperation, and unaesthetic reconstructive outcomes after mastectomy. Furthermore, the prolonged recovery can delay adjuvant oncologic regimens. This study aims to explore the role of breast surface area as a risk factor for mastectomy skin flap necrosis and to identify predictive clinical measurements.

METHODS

The authors retrospectively identified patients who underwent immediate breast reconstruction (N = 926 breasts) by 2 surgeons at a single institution between 2011 and 2021. Preoperative breast measurements such as nipple-notch (NN) distance, nipple-inframammary fold (NF) distance, chest width (CW), breast circumference (BC), and breast height (BH) were used to estimate breast surface area. Univariate analysis and receiver operating characteristic curves were used to determine predictive measurements and optimal cutoff values.

RESULTS

When approximated using either a cone without base or a half ellipsoid, larger surface area was a significant risk factor for mastectomy skin flap necrosis (P = 0.027 and P = 0.022, respectively). Larger NN, NF, CW, BC, and BH measurements were significant predictors of necrosis (P < 0.05). Surface area (cone without base) greater than 212 cm2, surface area (half ellipsoid) greater than 308 cm2, NN distance greater than 27 cm, NF greater than 8.5 cm, CW greater than 15 cm, BC greater than 29 cm, and BH greater than 10.5 cm are all values shown to increase the incidence of necrosis.

CONCLUSIONS

Larger breast surface area is an independent risk factor for breast skin necrosis. Preoperative breast measurements can be a useful adjunct for predicting necrosis in postmastectomy patients.

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.

“Hook Shape” Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series

INTRODUCTION

Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results.

MATERIALS AND METHODS

From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases.

RESULTS

Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results.

CONCLUSION

The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II).

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.

Conventional versus modified nipple sparing mastectomy in immediate breast reconstruction: Complications, aesthetic, and patient-reported outcomes

Background

Nipple-sparing mastectomy (NSM) followed by immediate breast reconstruction (IBR) is the optimal surgical treatment for breast cancer. However, investigations are ongoing to improve the surgical technique to achieve better results. This study aimed to evaluate the outcomes of modified NSM (m-NSM), which preserves the anterior lamellar fat layer, in patients who underwent IBR.

Methods

All patients who underwent modified NSM (m-NSM) or conventional NSM (c-NSM) followed by IBR using autologous tissue or implants were retrospectively reviewed between January 2014 and January 2021. Two mastectomy types were compared in terms of postoperative complications and aesthetic outcomes using panel assessment scores by physicians and reported outcomes using Breast-Q. In addition, postoperative evaluations of the thickness of mastectomy flap was performed using CT scan images.

Results

A total of 516 patients (580 breasts) with NSM (143 breasts with c-NSM and 437 breasts with m-NSM) followed by IBR were reviewed. The mean ± SD flap thickness was 8.48 ± 1.81 mm in patients who underwent m-NSM, while it was 6.32 ± 1.15 mm in the c-NSM cohort (p = 0.02). The overall major complications rate was lower in the m-NSM group (3.0% vs. 9.0%, p < 0.013). Ischemic complications of the mastectomy flap and nipple-areolar complex (NAC) were more in c-NSM, although the difference was not statistically significant. The mean panel assessment scores were higher in the m-NSM group (3.14 (good) and 2.38 (fair) in the m-NSM and c-NSM groups, respectively; p < 0.001). Moreover, m-NSM was associated with greater improvements in psychosocial (p < 0.001) and sexual (p = 0.007) well-being.

Conclusion

Preserving the anterior lamellar fat in NSM was associated with thicker mastectomy flap, overall lower rates of complications, including ischemia of the mastectomy flap and nipple-areolar complex, and was associated with better aesthetic outcomes and improved quality of life.

"Tear-Drop Appearance" Wrap: A Novel Implant Coverage Method for Creating Natural Contour in Prepectoral Prosthetic-Based Breast Reconstruction

Various implant wrapping methods with acellular dermal matrix (ADM) have been introduced, but most focus on random trimming and suturing aimed to maximize implant coverage. Here we present our clinical experience using a “tear-drop appearance” wrapping method to achieve natural contours through upper pole volume replacement. We retrospectively reviewed the data of 56 consecutive cases of prepectoral prosthetic-based breast reconstruction (PPBR) using this wrapping method following nipple-sparing mastectomy between March 2020 and June 2021. The “tear-drop appearance” wrapping design creates an anatomical tear-drop–shaped pocket to encourage lower pole fullness and create a natural contour through upper pole volume replacement by ADM. Patients’ baseline characteristics, operative data, and complications were analyzed. Aesthetic outcomes were measured using the BREAST-Q and Aesthetic Item Scale (AIS). A successful reconstruction was achieved without major complications and using a single ADM sheet. Four types and three sizes of ADMs were used. The mean resected breast tissue weight was 274.3 g, while the mean implant volume was 230.0 cc. The average BREAST-Q and AIS scores were 4.6 ± 0.8 and 4.5 ± 0.7, respectively. Owing to its simplicity, reproducibility, and effectivity, this method is an excellent implant coverage option that achieves a natural contour in PPBR.

The Impact of Preoperative Breast Volume on Development of Mastectomy Skin Flap Necrosis in Immediate Breast Reconstruction

BACKGROUND

Mastectomy skin flap necrosis (MSFN) can significantly impact outcome after immediate breast reconstruction. Several techniques exist to predict MSFN, but these may require additional testing and information, and they are often not available before surgery. We aim to identify whether breast volume, as calculated from preoperative mammography, can be used as a preoperative predictor of MSFN.

METHODS

A retrospective chart review from 2010 to 2020 resulted in 378 patients who underwent immediate implant-based breast reconstruction. Complete imaging data were available for 278 patients and 441 reconstructed breasts. Demographic, perioperative, and outcomes data were collected. Measurements from preoperative diagnostic mammograms were used to calculate breast volume. Univariate and multivariate analyses were used to evaluate the association of variables available preoperatively, including breast volume from mammogram and MSFN. Secondary analyses were performed for need for reoperation and loss of reconstruction.

RESULTS

On univariate analysis of MSFN development, demographic variables found to be significantly associated with MSFN included body mass index (P = 0.04), diabetes (P = 0.03), and breast volume calculated from routine mammography (P ≤ 0.0001). Average preoperative breast volume via mammography without and with MSFN was 970.6 mL (95% confidence interval [CI], 908.9-1032.3) and 1298.3 mL (95% CI, 1140.0-1456.5) (P < 0.0001), respectively. Statistically significant intraoperative variables for MSFN development included prolonged operative time (P = 0.005), greater initial tissue expander fill volumes (P ≤ 0.001), and prepectoral implant location (P = 0.02). Higher initial tissue expander fill volumes in implant-based reconstructions were associated with increased rates of MSFN, 264.1 mL (95% CI, 247.2-281.0) without MSFN and 349.9 mL (95% CI, 302.0-397.8) in the group with MSFN, respectively (P < 0.001). On multivariate analysis, preoperative imaging volume (P = 0.02) was found to be significant, whereas body mass index and diabetes lost significance (P = 0.40) in association with MSFN.

CONCLUSIONS

The results of this study establish an association between larger breast volume on preoperative imaging and development of MSFN. This may be useful as a tool for more appropriate patient selection and guidance in the setting of immediate breast reconstruction.

Defining Mastectomy Skin Flap Necrosis: A Systematic Review of the Literature and a Call for Standardization

BACKGROUND

Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification.

METHODS

A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed.

RESULTS

Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14 studies (23.7 percent) provided two separate rates. The overall rate of mastectomy skin flap necrosis was 10.4 percent (range, 2.3 to 41.2 percent) and 15.3 percent (range, 4.7 to 39.0 percent), when reported per breast or per patient, respectively. Studies were categorized by mastectomy skin flap necrosis definition, including intervention (n = 33), depth (n = 20), area (n = 4), and timing (n = 2). Mastectomy skin flap necrosis rates were highest in studies defining necrosis by depth (15.1 percent), followed by intervention (9.6 percent), timing (6.4 percent), and area (6.3 percent). Necrosis rates among studies defining mastectomy skin flap necrosis by intervention, depth, and area were found to be statistically different (p < 0.001).

CONCLUSIONS

Reported mastectomy skin flap necrosis definitions and outcomes vary significantly in the existing literature. For accurate characterization and quantification, a clear, simplified, consensus definition must be adopted.

Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

BACKGROUND

Large and ptotic breasts are considered an anatomical contraindication for nipple sparing mastectomy (NSM). Necrosis rates can be as high as 76%. The authors examined whether targeted preshaping mastopexy/reduction combined with simultaneous two-stage preshaping of the implant pocket prepares for an uneventful implant reconstruction.

METHODS

Macromastia and ptosis patients opting for risk-reducing NSM or having a peripherally localized carcinoma in situ, were offered a two-stage mastopexy/reduction simultaneously with preshaping of the implant pocket by subpectoral expansion. Only the inferior pedicle bearing the nipple-areola complex (NAC), remained. A delayed secondary NSM and tissue expander-to-implant reconstruction was scheduled 3 months later. The use of an acellular dermal matrix (ADM) was not necessary because the capsule around the expander created a hammock supporting the definite prosthesis. Follow up was at 2 weeks, 3 months, and 6 months.

RESULTS

Forty-one procedures were performed in 24 patients. The mean age was 45±12.08 years (range, 22 to 72 years). Patients' mean body mass index (BMI) was 26.79 kg/m2 (range, 19 to 35 kg/m2). One patient had diabetes and two smoked. One transient epidermolysis of the NAC occurred in each stage. No NAC or skin necrosis occurred; no implant had to be removed.

CONCLUSIONS

A two-stage mastopexy/reduction, simultaneously with preshaping of the implant pocket by tissue expansion and followed by a 3-month delayed secondary NSM with tissue expander-to-implant reconstruction is a safe technique in large ptotic breasts.

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.

Comparing Incision Choices in Immediate Microvascular Breast Reconstruction after Nipple-Sparing Mastectomy: Unique Considerations to Optimize Outcomes

BACKGROUND

Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature.

METHODS

A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication.

RESULTS

Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without.

CONCLUSIONS

Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients

BACKGROUND

Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes.

METHODS

Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed.

RESULTS

There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025).

CONCLUSIONS

Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

Quantifying the Effect of Topical Nitroglycerin on Random Pattern Flap Perfusion in a Rodent Model: An Application of the ViOptix Intra.Ox for Dynamic Flap Perfusion Assessment and Salvage

BACKGROUND

Near-infrared spectroscopy can detect changes in tissue oxygenation postoperatively that predict flap necrosis. The authors hypothesized that this technology can be applied along with topical nitroglycerin to measure an improvement in tissue oxygenation that correlates with tissue salvage.

METHODS

Dorsal, random pattern flaps measuring 10 × 3 cm were raised using Sprague-Dawley rats. Tissue oxygenation was measured after flap elevation in 10 locations using the ViOptix Intra.Ox. Animals were divided into three groups that received 30 mg of topical nitroglycerin daily, twice-daily, or not at all. Oxygenation measurements were repeated on postoperative day 1 and animals were euthanized on day 7 and evaluated for tissue necrosis.

RESULTS

Tissue necrosis was greatest in controls (51.3 mm) compared to daily (28.8 mm) and twice-daily nitroglycerin (18.8 mm; p = 0.035). Three flap perfusion zones were identified: healthy (proximal, 50 mm), necrotic (distal, 20 mm), and watershed. Immediate postoperative tissue oxygenation was highest in healthy tissue (57.2 percent) and decreased to 33.0 and 19.3 percent in the watershed and necrotic zones, respectively (p < 0.001). One day after treatment with nitroglycerin, oxygenation in the healthy zone did not increase significantly (mean difference, -1.5 percent). The watershed (17.8 percent; p < 0.001) and necrotic zones (16.3 percent; p <0.001) did exhibit significant improvements that were greater than those measured in control tissues (7.9 percent; both p < 0.001).

CONCLUSIONS

Serial perfusion assessment using the ViOptix Intra.Ox measured a significant improvement in flap oxygenation after treatment with topical nitroglycerin. Within the watershed area of the flap, this increase in tissue oxygenation was associated with the salvage of ischemic tissue.

Evolving Trends in Surgical Management of Breast Cancer: An Analysis of 30 Years of Practice Changing Papers

The management of breast cancer has evolved into a multidisciplinary evidence-based surgical speciality, with emphasis on conservative surgery. A number of landmark trials have established lumpectomy followed by radiation as the standard of care for many patients. The aim of this study is to construct a narrative review of recent developments in the surgical management of breast cancer and how such developments have impacted surgical practice. A comprehensive literature search of Pubmed was conducted. The latest search was performed on October 31^st, 2020. Search terms “breast cancer” were used in combinations with specific key words and Boolean operators relating to surgical management. The reference lists of retrieved articles were comprehensively screened for additional eligible publications. Articles were selected and reviewed based on relevance. We selected publications in the past 10 years but did not exclude commonly referenced and highly regarded previous publications. Review articles and book chapters were also cited to provide reference on details not discussed in the academic literature. This article reviews the current evidence in surgical management of early-stage breast cancer, discusses recent trends in surgical practice for therapeutic and prophylactic procedures and provides commentary on implications and factors associated with these trends.

Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss

BACKGROUND

Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM.

METHODS

Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses.

RESULTS

From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75).

CONCLUSIONS

Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis

BACKGROUND

Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group.

METHODS

Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction.

RESULTS

There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008).

CONCLUSIONS

When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc).

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 .

The Use of DCE-MRI to Evaluate the Blood Supply to the Nipple-Areola Complex: A Study in 245 Asian Women

BACKGROUND

Understanding the main blood supply to the nipple-areola complex (NAC) is important for breast plastic surgery. However, previous reports have involved studies of cadavers and small sample sizes.

OBJECTIVES

This study aimed to identify and classify the in vivo blood supply to the NAC based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

METHODS

DCE-MRI images of 393 breasts in 245 Asian women obtained from March 2012 to October 2019 were included retrospectively. Axial, coronal, and sagittal maximum-intensity projection images were evaluated to identify all vessels supplying the NAC. Blood supply to the NAC was classified into 9 anatomic zones: superomedial (Ia), medial (Ib), inferomedial (Ic), superolateral (IIa), lateral (IIb), inferolateral (IIc), central (III), inferior (IV), and superior (V).

RESULTS

A total of 637 source vessels were identified in 393 breasts. Of the 393 breasts, 211 (53.7%) were supplied by a single zone, 132 (33.6%) by 2 zones, 38 (9.7%) by 3 zones, and 12 (3.1%) by 4 zones. Of the 637 vessels, 269 (42.2%) vessels were in zone Ia, 180 (28.3%) vessels were in zone IIa, and <10% of vessels were in the other zones. The number of NAC perfusion zones (P = 0.093) and the distribution of source vessels (P = 0.602) did not differ significantly between the left and right breasts.

CONCLUSIONS

DCE-MRI provides a clear indication of the blood supply to the NAC. Blood vessels from the superomedial and superolateral zones were the predominant sources of blood supplying the NAC.

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.

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.

The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model

BACKGROUND

Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is a novel device that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis.

METHODS

Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis.

RESULTS

Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively.

CONCLUSIONS

Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.

Post-Operative Complications and Nipple Necrosis Rates Between Conventional and Robotic Nipple-Sparing Mastectomy

Purpose

This study is to directly compare surgical outcomes between conventional nipple-sparing mastectomy (CNSM) and robot-assisted nipple-sparing mastectomy (RNSM).

Materials and Method

For this case–control study, 369 cases of 333 patients who underwent CNSM or RNSM with immediate reconstruction between November 2016 and January 2019 at Severance Hospital in Seoul, Republic of Korea were reviewed. Patients with stage IV breast cancer (n = 1), receiving neoadjuvant chemotherapy (n = 43), or subjected to previous operations (n = 14) or radiotherapy on the breasts were excluded. The main outcomes were comparing rates of post-operative complications, of high-grade post-operative complications as defined by the Clavien-Dindo classification, and nipple necrosis between the CNSM and the RNSM groups.

Results

A total of 311 cases, including 270 CNSMs and 41 RNSMs, were analyzed. The rates of post-operative nipple necrosis (p = 0.026, 2.4 vs. 15.2%) and of high-grade post-operative complications (p = 0.031, 34.8 vs. 17.1%) in the RNSM group were significantly lower than those in the CNSM group.

Conclusion

RNSM was associated with lower rates of high-grade post-operative complications and nipple necrosis than CNSM for patients with small breast volumes and less ptotic breasts.

Types of Mastectomies and Immediate Reconstructions for Ipsilateral Breast Local Recurrences

Purpose: Ipsilateral-breast-local-recurrence (ILBLR) is a rare event with little data on immediate-breast-reconstruction (IBR). We report post-operative results of different types of mastectomy for ILBLR with or without IBR performed during a period of 40 months in order to analyze post-operative complications as main objective. Methods: We analyzed mastectomies performed for ILBLR after initial breast conservative treatment from January 2016 to April 2019. The characteristics of patients, surgery, complication rate, postoperative hospitalization have been determined. Results: Of the 207 mastectomies, 32.8% had an IBR: 31 nipple-sparing-mastectomy (NSM) and 37 skin-sparing-mastectomy (SSM) with 37 latissimus-dorsi-flap (LDF) IBR and 31 implant-IBR. Few reconstruction was performed for patients with body-mass-index ≥30 (OR = 0.214), infiltrating ductal carcinomas (OR = 0.272) and ASA-3 patients (OR = 0.254). In multivariate analysis, LDF-IBR was more often realized for NSM and for patients with BMI ≥25. The overall complication rate was 37.4%: 45.6 and 33.1% with and without IBR, respectively (p = 0.056). In multivariate analysis, BMI ≥25 (OR 2.02, p = 0.023), IBR (OR 1.9, p = 0.046) and tobacco (OR 2.17, p = 0.055) were correlated with higher risk of complications. There was no difference for Grade 2-3 complications rates for IBR and no IBR, respectively (14.7%: 10/68 and 9.3%: 13/139). In multivariate analysis, overall survival from date of mastectomy for local recurrence was significantly associated with interval time to local recurrence (OR 6.981). Conclusion: Salvage mastectomy and IBR is a good choice for ILBLR, particularly using flap reconstruction. NSM can be considered as a good option in selected patients for ILBLR for NSM and/or LDFR.

Effect of contralateral augmentation on postoperative complications after the second stage of tissue expander/implant breast reconstruction

Background

Contralateral augmentation mammoplasty in implant-based reconstruction could potentially lead to deterioration of the thickness of the mastectomy skin flap and increase postoperative complications of the reconstructed breast. We compared the complication rates of the reconstructed breast in the augmentation and no-augmentation groups among patients undergoing tissue expander/implant breast reconstruction.

Methods

Patients who underwent mastectomy followed by tissue expander/implant breast reconstruction between February 2010 and April 2018 were retrospectively reviewed. The primary outcome measures were complications and the need for a revision operation. The augmentation and no-augmentation groups underwent propensity score-matched analysis and the matched cases underwent multivariable logistic regression analysis.

Results

From the 234 patients in the augmentation group and 517 patients in the no-augmentation group, 200 propensity score-matched pairs were obtained. Analysis of the matched pairs revealed that the augmentation group as compared to the no-augmentation group showed a significantly higher overall complication rate (13.5 percent versus 6.5 percent; P=0.025) and revision operation rate (9.0 percent versus 3.0 percent; P=0.019). Multivariable conditional logistic regression analyses of the matched cases revealed that contralateral augmentation (odds ratio, 3.457; 95% confidence interval, 1.039-11.498; P=0.043) was associated with increased odds for a revision operation of the reconstructed breast.

Conclusions

This study investigated the postoperative complications of the reconstructed breast associated with contralateral augmentation mammoplasty in patients who underwent mastectomy followed by tissue expander/implant breast reconstruction. The augmentation group had a higher revision operation rate than did the no-augmentation group. A clinical evaluation of the risks and benefits of contralateral augmentation and preoperative counseling may be indicated for patients who are undergoing implant-based breast reconstruction and are candidates for contralateral augmentation mammoplasty.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Free Nipple Grafting and Nipple Sharing in Autologous Breast Reconstruction after Mastectomy

Nipple sparing mastectomy is gaining popularity in recent years, as it provides superior aesthetic results and has a positive impact on the psychological well-being of patients. However, patients with macromastia and high grade ptosis are not good candidates for nipple sparing mastectomy due to a high risk for nipple necrosis; for these patients, the free nipple grafting (FNG) is an excellent option following autologous reconstruction. We herein present our experience with FNG for women with large and ptotic breasts undergoing mastectomy and autologous reconstruction. We also present the option of splitting a single nipple-areolar complex to provide 2 grafts for bilateral nipple reconstruction. This retrospective study is based on data collected between 2014 and 2019 at a single institution. We report on 7 patients (13 grafts): 5 patients underwent FNG (4 bilateral, 1 unilateral) and 2 patients had a single nipple split into 2 parts to create 2 nipple-areolar complexes. Of the 13 grafts, 9 had complete take, 3 had almost complete take, and only 1 graft was lost. Overall patient satisfaction from the procedure was high. The use of FNG is an excellent reconstructive option, as it preserves the patient's own nipple in terms of color, shape, and texture. The procedure can be executed as part of a direct single-staged reconstruction for patients who are at a high risk for nipple necrosis.

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

Background

Nipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR.

Methods

We retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis.

Results

Data from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis.

Conclusions

Compared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple.

•

Periareolar incision shows higher complication rate in nipple-sparing mastectomy.

•

Periareolar incision is a risk factor for nipple-areolar complex necrosis.

•

Other risk factors include tumor-nipple distance and breast weight.

Can I Keep My Nipple? Factors Influencing the Surgical Decision between Skin-Sparing and Nipple-Sparing Mastectomy

Both skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are well accepted in the management of breast cancer. Factors that influence the decision of choosing one of these techniques over the other, however, remain to be well elucidated. From January 2010 to December 2017, 734 patients at our institution underwent one of these two procedures. Factors differentiating these patient cohorts were compared. In this study, 196 (26.7%) underwent NSM and 538 (73.3%) underwent SSM. The median age of patients at the time of surgery was 50 years (range, 22–78 years). On multivariate analysis, younger patient age, insurance type, BRCA1 mutation status, smaller breast size (by weight), and those who did not undergo neoadjuvant chemotherapy were more likely to undergo NSM. Surgeon also was an independent predictor of whether patients had NSM or SSM. There may be many factors that play into the decision to pursue NSM versus SSM, but younger patient age, BRCA mutation status, breast size, and whether the patient had neoadjuvant chemotherapy may be key among them. Insurance status may also be a factor for some patients. Aside from these factors, some surgeons may be more or less inclined to perform NSM.

Nipple-sparing mastectomy through periareolar incision with immediate reconstruction

Purpose

Nipple-sparing mastectomy (NSM) has become increasingly popular due to improved cosmesis without compromising oncologic safety. Radial and inframammary incisions are usually used to achieve NSM, with periareolar incisions usually being avoided because of the risk to nipple-areola complex viability. In an attempt to maximize esthetic effects, we performed NSM through periareolar incision with immediate reconstruction. We report our initial experience.

Methods

This case series consisted of all consecutive patients (n = 34) who underwent NSM through a periareolar incision in our institution between August 2017 and December 2018. All patients underwent NSM through periareolar incision followed by immediate reconstruction with an implant or deep inferior epigastric perforator flap. Patient demographics, tumor and treatment characteristics, and short-term postoperative outcomes were reviewed.

Results

The mean patient age was 46.74 ± 6.69 years (range, 38–62 years), and the mean operation time was 96.68 ± 28.00 minutes. Indications included in situ cancer in 12 cases and invasive cancer in 22 cases. There was 1 major complication (postoperative hematoma) requiring operative reintervention. No other complications including fistula, implant exposure, or reconstruction failure was observed. At the time of writing, no case of local recurrence has been observed.

Conclusion

Our initial report shows that NSM with immediate reconstruction may successfully be performed through periareolar incision. This method maximizes esthetic effects and may be an appropriate surgical option for NSM.

The influence of contralateral breast augmentation on the development of complications in direct-to-implant breast reconstruction

BACKGROUND

Simultaneous contralateral augmentation in direct-to-implant (DTI) breast reconstruction may increase the risk of skin flap necrosis on the reconstruction side due to increased tension on the skin flap when implants are larger than the original breast size. The purpose of this study was to evaluate whether the contralateral augmentation procedure affects complications in unilateral DTI breast reconstruction.

METHODS

Patients who underwent immediate unilateral DTI breast reconstruction from January 2013 to July 2017 were included in this study. Data were collected through retrospective review of individual medical records. The primary outcome variable was the development of perioperative complications including skin flap necrosis. Univariable and multivariable logistic regression analyses were performed to identify risk factors for complications.

RESULTS

A total of 121 patients who underwent unilateral immediate DTI breast reconstruction were included in this study. Twenty-one patients (17.4%) underwent simultaneous contralateral augmentation mammoplasty and 100 patients (82.6%) underwent DTI without contralateral augmentation. Overall complications were not different between the contralateral augmentation and no-augmentation groups (23.8% vs. 31%, respectively, p = 0.512). The frequency of skin flap necrosis in the augmentation group (14.3%) was not significantly different from that in the no-augmentation group (18.0%, p > 0.999). In multivariable analysis, mastectomy weight was the only predictor for complications (p = 0.053) and contralateral augmentation was not associated with development of complications.

CONCLUSION

Contralateral breast augmentation in DTI breast reconstruction is not a risk factor for complications and can be safely performed in selected patients.

Risk Factors for Skin Flap Necrosis in Breast Cancer Patients Treated with Mastectomy Followed by Immediate Breast Reconstruction

BACKGROUND

Skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are the standard techniques for achieving a cosmetic outcome, but necrosis of a cutaneous flap including the nipple-areolar complex (NAC) is a serious complication. To analyze the risk factors for skin flap necrosis, we retrospectively evaluated a clinical database of breast cancer patients treated with mastectomy followed by immediate breast reconstruction.

METHODS

Four hundred and twelve cases were consecutively recorded between 2006 and 2016. Body weight (BW), body mass index (BMI), distance from NAC to referent tumor, distance from overlying skin to the tumor and weight of breast resection (WBR) as measured in the operating theater were included in the statistical analysis.

RESULTS

NSM, SSM and total mastectomy were performed in 123 (30%), 96 (23%) and 193 cases (47%), respectively. A tissue expander was used in 379 cases (92%), a silicone implant in 8 (2%) and autologous breast reconstruction in 25 (6%). Skin flap necrosis was found in 7% of all cases and NAC necrosis in 13% of NSM cases. In a univariate analysis, BW, NSM and WBR were risk factors for skin flap necrosis, and BW, BMI and WBR were risk factors for NAC necrosis. In a multivariate analysis, NSM and WBR remained significant risk factors for skin flap necrosis, and WBR was a significant risk factor for NAC necrosis.

CONCLUSIONS

WBR is an important risk factor for skin flap necrosis. Especially, NAC necrosis should be considered for patients with large-volume breasts who undergo NSM and immediate breast reconstruction.

Ischemic Complications after Nipple-sparing Mastectomy: Predictors of Reconstructive Failure in Implant-based Reconstruction and Implications for Decision-making

Background:

Mastectomy flap and nipple–areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated.

Methods:

All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed.

Results:

Out of 1045 NSMs, 70 cases (6.7%) had major ischemic complications. Fifty-two cases (74.3% of major ischemic complications) had isolated major mastectomy flap necrosis, 7 (10%) had full NAC necrosis and 11 (15.7%) had both. Five cases (7.1%) underwent implant exchange at the time of debridement and 15 cases (21.4%) required explantation. Explanted cases had significantly lower body mass index (22.3 versus 24.7, P = 0.013) and larger debridement size (49.5 cm² versus 17.6 cm², P = 0.0168). Additionally, explanted cases had a higher rate of acellular dermal matrix/mesh (100% versus 45.5%, P < 0.0001), prior radiation (20.0% versus 0%, P = 0.0083), immediate implants (46.7% versus 20.0%, P = 0.0491), major infection (30.0% versus 1.8%, P = 0.028), and both major mastectomy flap/NAC necrosis (33.3% versus 10.9%, P = 0.0494).

Conclusions:

NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.

Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes

To review current literature on the outcomes, techniques and trend of endoscopic-assisted breast surgery (EABS) in the management of breast cancer over a 20 years period Materials and Methods: Literature search was performed using PubMed/Medline database from 1st January 1998 to 31st December 2018 using the terms "endoscopy", "endoscopy-assisted", "breast cancer", "mastectomy" and "breast conserving surgery". Additional studies were also identified by reviewing references of relevant articles. Only case series and cohort studies were included in this review. Oncological and surgical outcome measures as well as detailed technical aspects were discussed. Results: EABS was comparable in terms of oncological, surgical as well as aesthetic outcomes if compared to conventional techniques. Patient selection and important adjuncts are essential to ensure successful and safe conduct of EABS. Conclusions: Standardization of techniques, practice guidelines and objective outcome assessments methods might pave the way for better conduct of EABS and place EABS as one of the standards of care for breast cancer care.

Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction

INTRODUCTION

The morphological result of nipple-areola complex (NAC) reconstruction may be disappointing for patients who undergo skin-sparing mastectomies and immediate breast reconstruction, followed by secondary reconstruction of the nipple-areola complex.The aim of this study was to analyze patient satisfaction after nipple-sparing mastectomy and immediate breast reconstruction with a deep inferior epigastric perforator flap.

MATERIALS AND METHODS

Our retrospective study involved all patients who underwent an immediate breast reconstruction after unilateral mastectomy with conservation of the NAC. The following three kinds of surgical approach were used: mastectomy with periareolar incision, mastectomy with hemiperiareolar incision and lateral extension, and mastectomy with inverted-T mammoplasty incision. Our study was based on a survey using a standardized questionnaire and a Likert scale to report patient satisfaction on the basis of criteria defined by the investigators.

RESULTS

We evaluated 17 patients. All reconstruction patients were satisfied or very satisfied with the overall aesthetic appearance, projection, and volume as well as the appearance of scarring on the reconstructed breast. None of our patients reported dissatisfaction in response to the criteria under evaluation. A periareolar incision was used most often to perform the mastectomy (10 patients). Partial NAC necrosis was observed in five patients, without negatively influencing their perception of the morphological outcome of their reconstruction.

CONCLUSIONS

Immediate breast reconstruction using a deep inferior epigastric perforator free flap after nipple-sparing mastectomies met with a high rate of general satisfaction among patients and resulted in a low rate of nipple-areola complex necrosis.