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La Padula S, Pensato R, Al-Amer R, Hersant B, Meningaud JP, Noel W, D'Andrea F, Rocco N. Three Pedicle-Based Nipple-Sparing Skin-Reducing Mastectomy Combined with Prepectoral Implant-Based Breast Reconstruction. Plast Reconstr Surg 2024; 154:430e-441e. [PMID: 37749785 DOI: 10.1097/prs.0000000000011092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) and immediate breast reconstruction have demonstrated positive aesthetic outcomes and high patient satisfaction. However, challenges arise when performing NSM on patients with large and ptotic breasts because of the higher risk of nipple-areola complex (NAC) necrosis. This study proposes a new technique: the three pedicle-based nipple-sparing skin-reducing mastectomy (TP-NSSRM), combined with direct-to-implant (DTI) breast reconstruction, aimed at reducing complications. METHODS A prospective study was conducted from November of 2021 to April of 2022, enrolling patients with large and drooping breasts requiring mastectomy for breast cancer treatment or risk reduction. Patient selection criteria included a sternal notch-to-nipple distance of greater than or equal to 23 cm, grade 3 ptosis, and eligibility for immediate prepectoral DTI breast reconstruction. Patient satisfaction was assessed using BREAST-Q modules. RESULTS Seventy-two TP-NSSRM procedures combined with immediate DTI-based breast reconstruction were performed on a total of 45 patients. High patient satisfaction was observed, and statistically significant improvements were noted in postoperative BREAST-Q scores ( P = 0.001). The complication rate was low, and preservation of the nipple-areola complex was achieved in all cases. CONCLUSIONS The TP-NSSRM technique offers a potential solution for patients with large and drooping breasts undergoing NSM. It aims to minimize complications and achieve satisfactory outcomes. This study demonstrates favorable results in terms of patient satisfaction and quality of life. Further research and long-term follow-up are necessary to validate these findings and evaluate the long-term outcomes of this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Simone La Padula
- From the Department of Plastic and Reconstructive Surgery, Università Degli Studi di Napoli Federico II
- Breast Unit, Federico II University Hospital
| | - Rosita Pensato
- From the Department of Plastic and Reconstructive Surgery, Università Degli Studi di Napoli Federico II
| | | | - Barbara Hersant
- Department of Plastic, Reconstructive, and Maxillofacial Surgery, Henri Mondor Hospital, University Paris XII
| | - Jean Paul Meningaud
- Department of Plastic, Reconstructive, and Maxillofacial Surgery, Henri Mondor Hospital, University Paris XII
| | - Warren Noel
- Department of Infectious Disease-Dermatology and Plastic Surgery, University Hospital de la Réunion
| | - Francesco D'Andrea
- From the Department of Plastic and Reconstructive Surgery, Università Degli Studi di Napoli Federico II
- Breast Unit, Federico II University Hospital
| | - Nicola Rocco
- Breast Unit, Federico II University Hospital
- Department of Advanced Biomedical Sciences, University of Naples Federico II
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Awaida CJ, Bernier C, Bou-Merhi JS, Trabelsi NO, Gagnon A, El-Khatib A, Harris PG, Odobescu A. Staged Mastopexy before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Breast Reconstruction. Plast Reconstr Surg 2024; 153:864e-872e. [PMID: 37335584 DOI: 10.1097/prs.0000000000010823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Breast reconstruction following nipple-sparing mastectomy (NSM) in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before NSM and reconstruction in the authors' institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3%) were reconstructed with free abdominal flaps, six (7.1%) with tissue expanders, and 66 (78.6%) with permanent subpectoral implants and acellular dermal matrix. There was one case of postoperative superficial nipple-areola complex epidermolysis (1.2%), and two cases of partial mastectomy skin flap necrosis (2.4%). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION Mastopexy or breast reduction before NSM and reconstruction is a safe procedure with a low risk of ischemic complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Cyril J Awaida
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Christina Bernier
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Joseph S Bou-Merhi
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | | | - Alain Gagnon
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Arij El-Khatib
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Patrick G Harris
- From the Division of Plastic and Reconstructive Surgery, University of Montreal Hospital Center
| | - Andrei Odobescu
- Department of Plastic Surgery, University of Texas Southwestern
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Shih L, Doval A, Burns HR, Kaplan J, Ellsworth WA, Chevray PM, Spiegel AJ, Friedman JD. Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg 2024; 91:249-257. [PMID: 38428233 DOI: 10.1016/j.bjps.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/27/2023] [Accepted: 02/04/2024] [Indexed: 03/03/2024]
Abstract
Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.
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Affiliation(s)
- Linden Shih
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
| | - Andres Doval
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Heather R Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jordan Kaplan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Warren A Ellsworth
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Pierre M Chevray
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Aldona J Spiegel
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Jeffrey D Friedman
- Division of Plastic Surgery, Institute for Reconstructive Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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Daly L, Tsai J, Stone K, Wapnir I, Karin M, Wan D, Momeni A. Nipple-areola-complex preservation and obesity-Successful in stages. Microsurgery 2024; 44:e31043. [PMID: 37013250 DOI: 10.1002/micr.31043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 01/12/2023] [Accepted: 03/09/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population. METHODS Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed. RESULTS Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission. CONCLUSIONS Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.
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Affiliation(s)
- Lauren Daly
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jacqueline Tsai
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Kim Stone
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Irene Wapnir
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Mardi Karin
- Division of General Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Derrick Wan
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Mayer HF, Huatuco RMP, Ramírez MF, Buena ITP. Breast Reconstruction after Blunt Breast Trauma: Systematic Review and Case Report Using the Ribeiro Technique. Arch Plast Surg 2023; 50:550-556. [PMID: 38143835 PMCID: PMC10736189 DOI: 10.1055/a-2121-7560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 06/15/2023] [Indexed: 12/26/2023] Open
Abstract
Blunt breast trauma occurs in 2% of blunt chest injuries. This study aimed to evaluate the evidence on breast reconstruction after blunt trauma associated with the use of a seat belt. Also, we describe the first case of breast reconstruction using the Ribeiro technique. In November 2022, a systematic search of MEDLINE, EMBASE, and Google Scholar databases was conducted. The literature was screened independently by two reviewers, and the data was extracted. Our search terms included breast, mammoplasty, blunt injury, and seat belts. In addition, we present the case of a woman with a left breast deformity and her reconstruction using the inferior Ribeiro flap technique. Six articles were included. All included studies were published between 2010 and 2021. The studies recruited seven patients. According to the Teo and Song classification, seven class 2b cases were reported. In five cases a breast reduction was performed in the deformed breast with different types of pedicles (three superomedial flaps, one lower flap, one superior flap). Only one case presented complications. The case here presented was a type 2b breast deformity in which the lower Ribeiro pedicle was used successfully without complications during follow-up. Until now there has been no consensus on reconstructive treatment due to the rarity of this entity. However, we must consider surgical treatment individually for each patient. We believe that the Ribeiro technique is a feasible and safe alternative in the treatment of posttraumatic breast deformities, offering very good long-term results.
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Affiliation(s)
- Horacio F. Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - René M. Palacios Huatuco
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Mariano F. Ramírez
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
| | - Ignacio T. Piedra Buena
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute, Buenos Aires, Argentina
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Sardu C, Gatta G, Pieretti G, Onofrio ND, Balestrieri ML, Scisciola L, Cappabianca S, Ferraro G, Nicoletti GF, Signoriello G, Sportiello L, Savarese G, Melchionna M, Ciccarelli F, La Forgia D, Paolisso G, Marfella R. SGLT2 breast expression could affect the cardiovascular performance in pre-menopausal women with fatty vs. non fatty breast via over-inflammation and sirtuins' down regulation. Eur J Intern Med 2023; 113:57-68. [PMID: 37062642 DOI: 10.1016/j.ejim.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVES To evaluate the expression of sodium-glucose transporter 2 (SGLT2), inflammatory cytokines, and sirtuins in breast fat tissue at baseline, and serum cytokines of fatty vs. non-fatty pre-menopausal women at baseline, and at 12 months of follow-up. To correlate SGLT2/cytokines/sirtuins expression to clinical variables, and their changes (Δ) at follow-up, as intima-media wall thickness (IMT), left ventricle mass (LVM), left ventricle ejection fraction (LVEF), and myocardial performance index (MPI), and its normalization. BACKGROUND Pre-menopausal women with the lowest breast fat density (fatty breast) vs. higher breast fat density (non-fatty breast) are a high-risk population for cardiovascular diseases and worse prognosis. METHODS We analyzed SGLT2/cytokines/sirtuins of excised fatty breasts of fatty vs. non-fatty pre-menopausal women. We correlated SGLT2/cytokines/sirtuins to Δ IMT, Δ LVM, Δ LVEF, and Δ MPI, and normal cardiac performance (NCP) at 1 year of follow-up. RESULTS fatty vs. non-fatty breast over-expressed SGLT2/inflammatory cytokines, with lowest values of sirtuins (p<0.05). We found a direct correlation between SGLT2 (R2 0.745), TNFα (R2 0.262), and ΔMPI (p<0.05), and an inverse correlation between breast density (R2 -0.198), SIRT-3 (R2-0.181), and ΔMPI (p<0.05). Fatty breast (0.761, CI 95% [0.101-0.915]), SGLT2 (0.812, CI 95% [0.674-0.978]) and SIRT-3 (1.945, CI 95% [1.201-3.148]) predicted NCP at 1 year of follow-up. CONCLUSIONS fatty vs. non-fatty breast women over-expressed SGLT2/inflammatory cytokines, and down-regulated breast sirtuins. SGLT2/inflammatory cytokines expression and inversely the tissue sirtuin 3 (tSIRT3) and breast percentage density linked to ΔMPI at 1 year of follow-up. Fatty breast and SGLT2 inversely predicted NCP; SIRT-3 increased the probability of NCP at 1 year of follow-up.
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Affiliation(s)
- Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, Naples 80138, Italy; Cardiovascular Diseases Department, Gemelli Molise S.p.a, Campobasso, Italy.
| | - Gianluca Gatta
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli" Italy.
| | - Gorizio Pieretti
- Plastic Surgery Unit, University of Campania "Luigi Vanvitelli", Italy.
| | - Nunzia D' Onofrio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli" Italy.
| | | | - Lucia Scisciola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, Naples 80138, Italy.
| | | | - Giuseppe Ferraro
- Plastic Surgery Unit, University of Campania "Luigi Vanvitelli", Italy.
| | | | - Giuseppe Signoriello
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Italy.
| | - Liberata Sportiello
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Italy.
| | | | - Mario Melchionna
- Cardiovascular Diseases Department, Gemelli Molise S.p.a, Campobasso, Italy.
| | | | | | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, Naples 80138, Italy; Mediterranea Cardiocentro, Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, Naples 80138, Italy; Mediterranea Cardiocentro, Naples, Italy.
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Radparvar J, Piplani C, Chatterjee A, Nardello SM. Oncoplastic Surgery in the Large-Breasted Breast Cancer gene Patient: A Staged Step to Enable Nipple Sparing Mastectomy. Am Surg 2023; 89:2049-2051. [PMID: 34053225 DOI: 10.1177/00031348211023454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with macromastia and/or moderate-severe ptosis who desire mastectomy are typically offered skin sparing mastectomies. Recent technical advances have broadened the inclusion criteria to allow for nipple sparing mastectomy (NSM) in this population; however, they have been limited to patients with unifocal disease. We report on the multidisciplinary approach used to offer a NSM to a patient with multicentric triple-negative breast cancer and symptomatic macromastia with severe ptosis in the setting of positive genetic testing. We discuss the combination of a staged oncoplastic approach with neoadjuvant and adjuvant chemotherapy, as well as the foundations of these approaches. We encourage further research and inclusion of patients such as ours in the criteria for NSM.
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Affiliation(s)
| | - Charoo Piplani
- Clara Swain Mission Hospital, Bareilly, Uttar Pradesh, India
| | - Abhishek Chatterjee
- Tufts Medical Center Community Care, Stoneham, MA, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tufts Medical Center, Boston, MA, USA
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Expanding Candidacy for Nipple-sparing Mastectomy in Women with Large or Ptotic Breasts: Staged Reconstruction Outcomes. Plast Reconstr Surg Glob Open 2023; 11:e4767. [PMID: 36776594 PMCID: PMC9911193 DOI: 10.1097/gox.0000000000004767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/21/2022] [Indexed: 02/04/2023]
Abstract
Development of the nipple-sparing mastectomy (NSM) technique has dramatically improved breast reconstruction, and preservation of the nipple-areolar complex (NAC) positively influences patient satisfaction. However, women with large, ptotic breasts have historically not been candidates for NAC preservation due to impaired perfusion of the NAC leading to NAC loss. Although reduction mammoplasty has been reported as a strategy to increase candidacy for NSM, success rates and surgical outcomes for this staged approach are not well described in heterogeneous clinical scenarios. Methods We performed a retrospective chart review of all patients who underwent reduction mammoplasty followed by NSM at our institution between January 2014 and September 2020. Clinical and surgical characteristics were collected. All surgical complications, including NAC loss rates, were analyzed. Results Forty-one patients (74 breasts) underwent staged NSM during the defined time period. The average time between breast reduction mammoplasty and NSM was 213 days. Overall, 94.6% of NSM resulted in successful nipple preservation. There was no significant difference in the time interval from breast reduction mammoplasty to NSM between patients who had NAC loss (208 days) and those who did not (213 days, P = 0.87). Increasing age was significantly associated with risk of NAC loss (P = 0.002) in our cohort. Conclusions In women with breast ptosis (which precludes safe NSM), it is possible to first offer reduction mammoplasty to preserve the NAC for future NSM. Our data suggest that 3 months between staged procedures is a safe time frame.
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Outcomes of Nipple-sparing Mastectomy with Reconstruction after Recent Oncoplastic Wise-pattern Reduction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4731. [PMID: 36699213 PMCID: PMC9857552 DOI: 10.1097/gox.0000000000004731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/08/2022] [Indexed: 01/22/2023]
Abstract
For patients with large and/or ptotic breasts, a planned staged approach to nipple-sparing mastectomy (NSM) has been described. Less is known about surgical outcomes of unplanned staged NSM for management of positive margins after partial mastectomy with oncoplastic reduction. It is not clear from earlier studies whether an interval of less than 10 weeks between oncoplastic reduction and NSM is feasible, when a shorter interval is important for oncologic reasons. Methods This is a single institution analysis of patients from 2018 to 2021 with a diagnosis of invasive cancer or ductal carcinoma in situ who underwent NSM after oncoplastic breast reduction for positive margins or nodes. The primary endpoint measured was nipple loss. Secondary outcomes were need for operative re-intervention and wound complications. Results Nine patients (14 breasts) underwent partial mastectomy with oncoplastic Wise-pattern breast reduction, followed by NSM. Three patients underwent intersurgery chemotherapy. The average interval between oncoplastic reduction and NSM was 11.3 weeks when excluding patients undergoing chemotherapy (range 8-13 weeks). Thirteen breasts (93%) underwent pre-pectoral direct-to-implant reconstruction. One breast (7%) received autologous reconstruction. One breast required reoperation for seroma. The rate of partial or total nipple loss was 0%, with an average follow-up of 1.6 years. Conclusions Our experience demonstrates excellent outcomes from NSM after oncoplastic breast reduction, with the majority of patients undergoing single-stage pectoral direct-to-implant breast reconstruction. Overall, patients had a shorter intersurgery interval, compared with prior studies, with no cases of nipple loss. An intersurgery interval of 8 weeks may be feasible when avoiding delays is important for oncologic reasons.
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10
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Peled AW, Clavin NW. Novel Approaches to Breast Reconstruction. Surg Clin North Am 2022; 103:141-153. [DOI: 10.1016/j.suc.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Autologous Breast Reconstruction with Free Nipple–Areola Graft after Circumareolar (Skin Reducing) Mastectomy. J Pers Med 2022; 12:jpm12101588. [PMID: 36294726 PMCID: PMC9605625 DOI: 10.3390/jpm12101588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction of skin-sparing mastectomy (SSM) led to a paradigm shift in breast reconstruction. Primary reconstructions have become the therapy of choice. At the same time, immediate autologous reconstructions are oncologically safe and aesthetically pleasing. Our preferred SSM incision is the circumareolar with removal of nipple and areola (NAC). Adjustment of the skin envelope is well accomplished in mild-to-moderate ptotic breasts. We describe our technique consisting of circumareolar incision in SSM, keeping the NAC as a free graft, and immediate autologous reconstruction and immediate free NAC grafting on the flap. Aesthetic indications are slight asymmetries, ptotic breasts, large breasts where the reconstructed breast will be smaller than the original breast and where a Wise pattern is not indicated. Oncologic indications are risk-reducing mastectomies and tumors close to the NAC where resection would compromise the vitality of the NAC. We evaluated the healing of the NAC and the NAC position with regard to the breast shape. From 2019–2022, 296 autologous flaps were used for breast reconstruction. In 36 flaps, this technique was applied. Eighteen flaps were bilateral (nine patients). In total, we performed 15 inner thigh flaps and 21 DIEP flaps. No flap or NAC loss occurred. There was no wound healing complication at the breast, and no adjuvant chemotherapy or radiation therapy needed to be postponed. The advantages of this technique are (1) scar reduction with only one periareolar scar on the breast, which is also well concealed; (2) oncological safety in relation to the nipple and optimal visibility of the mastectomy cavity, which allows a meticulous mastectomy, especially important in risk-reducing mastectomies; (3) generally, fewer wound healing problems, especially fewer than with Wise pattern incision; (4) primary adjustment of the skin envelope and positioning of the NAC are easier to perform than in a secondary procedure; and (5) that the NAC is spared, and no secondary reconstruction is necessary. Disadvantages are that (1) the NAC must heal as a free graft and (2) that the sensitivity of the NAC is lower than in pedicled NAC transposition.
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Gulcelik MA, Dogan L, Karaman N, Bahcecitapar M, Ozaslan C. Oncoplastic Level II Surgical Techniques for Breast Cancer Treatment: Long-Term Outcomes. Breast Care (Basel) 2022; 17:24-30. [PMID: 35355700 PMCID: PMC8914188 DOI: 10.1159/000514468] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/16/2021] [Indexed: 02/03/2023] Open
Abstract
Background Problems in patients who could not get adequate surgical margins (SM) and good cosmetic results with breast-conserving surgery (BCS) have been overcome with the introduction of oncoplastic surgery (OPS) methods. The purpose of this study was the documentation of level II techniques and the presentation of long-term survival results. Methods The data on patients who had been prospectively registered in the database between 2007 and 2017 and who had been treated with level II OPS due to invasive breast cancer were examined. Results A total of 1,074 patients were included in the study. The most commonly applied level II oncoplastic techniques were performed in the upper outer quadrantectomy with racquet incision in 334 (31%) patients, inferior pedicle flaps in 294 (27.3%), and vertical mammoplasty in 140 (13%). Reexcision was performed in 96 patients (8.9%). Total breast conservation rate was 96%. Five-year disease-free survival (DFS) was 88%, local recurrence-free survival (LRFS) 93.6%, and overall survival (OS) 96%. Ten-year DFS was 72%, LRFS 85.4%, and OS 90.2%. Conclusion Level II OPS techniques have low reoperation and complication rates and a high rate of breast protection. The success of these techniques has been demonstrated in terms of long-term local control. Awareness of the fact that many patients who undergo OPS will not lose their breasts should be created, and regular training programs for OPS techniques should be conducted especially in developing countries. By revealing these results, it is hoped that the OPS and breast conservation rates will increase.
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Affiliation(s)
- Mehmet Ali Gulcelik
- Department of Surgical Oncology, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Lutfi Dogan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey,*Lutfi Dogan, Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara 06200 (Turkey),
| | - Niyazi Karaman
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Melike Bahcecitapar
- Department of Statistics, Hacettepe University, Faculty of Science, Ankara, Turkey
| | - Cihangir Ozaslan
- Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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King CA, Bartholomew AJ, Sosin M, Avila A, Famiglietti AL, Dekker PK, Perez-Alvarez IM, Song DH, Fan KL, Tousimis EA. A Critical Appraisal of Late Complications of Prepectoral versus Subpectoral Breast Reconstruction Following Nipple-Sparing Mastectomy. Ann Surg Oncol 2021; 28:9150-9158. [PMID: 34386913 DOI: 10.1245/s10434-021-10085-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) offers improved aesthetics without compromising oncologic safety. Subpectoral breast reconstruction has long been standard practice, although prepectoral reconstruction has recently resurged in popularity. Due to this recent paradigm shift, studies comparing long-term outcomes by reconstructive plane are lacking. METHODS A retrospective review was conducted on consecutive NSMs with implant-based reconstruction in either the prepectoral or subpectoral plane from 2014 to 2018. Patient demographics, implant specifications, and operative details were collected to evaluate primary outcomes of prosthetic failure and unplanned reoperations by reconstructive plane. Secondary outcomes included animation deformity, capsular contracture, rippling, plane change, and minor revisions, including fat grafting. Bivariate and multivariate analyses were performed to assess outcomes. RESULTS Overall, 405 NSMs were performed on 228 women (subpectoral = 202, prepectoral = 203), with a mean follow-up of 2.1 years (standard deviation 1.1). During the study period (2014-2018), a shift from subpectoral to predominantly prepectoral mastectomies occurred in 2017. Prepectoral reconstructions were more often direct-to-implant (DTI) compared with subpectoral (73.9% vs. 33.2%, p < 0.001). Prepectoral reconstruction demonstrated significantly reduced prosthetic failure (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.14-0.65) and unplanned reoperations (OR 0.43, 95% CI 0.24-0.77) compared with subpectoral reconstruction after controlling for implant characteristics and other possible confounders. Prepectoral patients experienced decreased animation deformity overall (19.7% vs. 0.0%, p < 0.001), with plane changes seen in 10.6% of subpectoral reconstructions for animation deformity correction. Prepectoral patients experienced an increase in rippling (15.3% vs. 6.1%, p = 0.003) without a significant increase in fat grafting (subpectoral = 11.6% vs. prepectoral = 12.3%, p = 0.829). CONCLUSIONS This single-institution experience compares late complications of prepectoral and subpectoral implant-based reconstruction following NSM. Prepectoral reconstruction can be safely performed with improved understanding of mastectomy planes, readily affords DTI reconstruction, and reduces animation deformity at the expense of rippling.
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Affiliation(s)
- Caroline A King
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Alex J Bartholomew
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Michael Sosin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Azalia Avila
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amber L Famiglietti
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Paige K Dekker
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Idanis M Perez-Alvarez
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - David H Song
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kenneth L Fan
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Eleni A Tousimis
- Department of Surgery, Division of Breast Surgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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Is Nipple-Sparing Mastectomy Indicated after Previous Breast Surgery? A Series of 387 Institutional Cases. Plast Reconstr Surg 2021; 148:21-30. [PMID: 34181601 DOI: 10.1097/prs.0000000000008097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous breast surgery does not represent an absolute contraindication for nipple-sparing mastectomy, although it may negatively interfere with surgical outcomes. The aim of the authors' study was to confirm the feasibility of nipple-sparing mastectomy after previous breast surgery, focusing on skin incisions and risk factors, complications, and oncologic outcomes. METHODS The authors retrospectively identified 368 patients who underwent 387 nipple-sparing mastectomies and reconstruction after previous surgery (quadrantectomy, breast resection, augmentation and reduction mammaplasty, mastopexy) at the European Institute of Oncology from January of 2003 to November of 2017. Patterns of skin incisions (i.e., radial, hemiperiareolar, periareolar, vertical pattern, inframammary fold, Wise-pattern, and round-block) for primary surgery and for mastectomy, type of reconstruction, and radiotherapy have been recorded. The authors collected data regarding early and late complications and further operations (implant change, fat grafting) performed within 2 years to improve cosmetic outcomes. Oncologic follow-up has been reported for in-breast recurrences. RESULTS Complete and partial nipple-areola complex necrosis occurred, respectively, in 2.8 percent and in 5.4 percent of cases. The authors recorded 5.4 percent failures resulting in implant removal. The analysis of risk factors for complications or for the need for further operations showed no significant association with skin incision for first surgery and mastectomy, use of the same skin incision, previous radiotherapy, or type of primary surgery. Five-year overall survival and disease-free survival were 99.1 and 93.8 percent, respectively. No nipple recurrence was recorded. CONCLUSIONS The authors' results confirm that nipple-sparing mastectomy can be a safe surgical procedure after previous breast surgery. Surgical planning should be tailored to each patient. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Nipple-Sparing Skin-Reducing Mastectomy for Women with Large and Ptotic Breasts: a 6-Year, Single-Centre Experience with the Bipedicled Dermal Flap Approach. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Deptula P, Yesantharao P, Wapnir I, Nguyen D. Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study. Ann Plast Surg 2021; 86:S395-S402. [PMID: 33470622 DOI: 10.1097/sap.0000000000002725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Peter Deptula
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Irene Wapnir
- Section of Surgical Oncology, Department of Surgery, Stanford University Medical Center, Stanford, CA
| | - Dung Nguyen
- From the Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA
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A Strategic Approach to Nipple-sparing Mastectomy Reconstruction with a Wide-based Inframammary Fold Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3053. [PMID: 32983800 PMCID: PMC7489662 DOI: 10.1097/gox.0000000000003053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/24/2020] [Indexed: 12/05/2022]
Abstract
The single biggest advancement in the aesthetic outcome of breast reconstruction following mastectomy has been the contribution of nipple-sparing mastectomy. By preserving the nipple–areolar complex, patients do not experience the same sense of loss that is observed in the setting of skin-sparing mastectomy. Despite this significant contribution, the challenge remains as to how surgeons can extend this option to larger-breasted patients or patients with significant breast ptosis. Several strategies have been described, including reduction mammoplasty before mastectomy, bipedicled simultaneous mastopexy with mastectomy, and free nipple grafting. The authors have developed a novel approach to nipple-sparing mastectomy that preserves the nipple–areolar complex on a wide-based inframammary fold (IMF) flap and uses indocyanine green perfusion imaging to successfully and reliably perform nipple-sparing mastectomy with immediate reconstruction in larger-breasted ptotic patients. Six patients underwent bilateral nipple-sparing mastectomies and immediate breast reconstruction with a wide-based IMF flap. All patients underwent immediate reconstruction with prepectoral placement of tissue expanders to treat either breast cancer or ductal carcinoma in situ (DCIS), and all patients successfully completed exchange of expander to implant. There were no complications with infection, seroma, mastectomy flap, or nipple necrosis. Aesthetic results were in line with other nipple-sparing techniques. The wide-based IMF flap with nipple preservation is a viable option for larger-breasted ptotic patients who might not otherwise be candidates for nipple-sparing mastectomy. The approach described is a combination of surgical technique and indocyanine green perfusion technology to deliver reproducible results, with an emphasis on surgical safety and avoidance of complications.
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Salibian AA, Frey JD, Karp NS, Choi M. Reply: Does Staged Breast Reduction before Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques. Plast Reconstr Surg 2020; 146:224e-225e. [PMID: 32740610 DOI: 10.1097/prs.0000000000006986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ara A Salibian
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, N.Y
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The Hybrid Delay: A New Approach for Nipple-sparing Mastectomy in Macromastia. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2940. [PMID: 32766079 PMCID: PMC7339346 DOI: 10.1097/gox.0000000000002940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/05/2020] [Indexed: 11/26/2022]
Abstract
Background: Patients with macromastia or breast ptosis can undergo a nipple-sparing mastectomy if their mastectomy flaps are delayed or if they are subjected to a breast reduction procedure and later undergo mastectomy. Methods: In this report, we describe a new technique to combine these two approaches by initially performing a subtotal mastectomy through a Wise keyhole incision in combination with the retention of the nipple -areolar complex on an inferior pedicle flap. A tissue expander and an allograft are routinely placed during this first stage. At a second stage, the inferior pedicle tissue is removed and submitted for pathological examination at the same time as the tissue expander is removed and replaced with a silicone or saline implant or autologous flap. Results: The Hybrid Delay procedure has been performed on three women (six breasts). Nipples were preserved in all patients. Final pathology did not reveal any cancer in the inferior pedicle preserved during the first procedure but removed and tested following the second. Conclusion: By allowing the nipple to be safely transferred using the inferior pedicle flap, and then removing the inferior pedicle tissue during the subsequent reconstructive stage, women with macromastia and breast ptosis can be offered nipple-sparing mastectomy in the usual 2-stage reconstructive timing.
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Kopkash K, Sisco M, Poli E, Seth A, Pesce C. The modern approach to the nipple‐sparing mastectomy. J Surg Oncol 2020; 122:29-35. [DOI: 10.1002/jso.25909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Katherine Kopkash
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Mark Sisco
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Elizabeth Poli
- Department of SurgeryUniversity of Chicago Chicago Illinois
| | - Akhil Seth
- Division of Plastic SurgeryNorthShore University HealthSystem Evanston Illinois
| | - Catherine Pesce
- Department of SurgeryNorthShore University HealthSystem Evanston Illinois
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Chu CK, Davis MJ, Abu-Ghname A, Winocour SJ, Losken A, Carlson GW. Implant Reconstruction in Nipple Sparing Mastectomy. Semin Plast Surg 2019; 33:247-257. [PMID: 31632208 DOI: 10.1055/s-0039-1696988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Albert Losken
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Grant W Carlson
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Park KU, Weiss A, Rosso K, Yi M, Hunt K, Kuerer H, Hanson SE, Candelaria R, Tevis S, Thompson A. Use of Mammographic Measurements to Predict Complications After Nipple-Sparing Mastectomy in BRCA Mutation Carriers. Ann Surg Oncol 2019; 27:367-372. [DOI: 10.1245/s10434-019-07704-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Indexed: 11/18/2022]
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Expanded Algorithm and Updated Experience with Breast Reconstruction Using a Staged Nipple-Sparing Mastectomy following Mastopexy or Reduction Mammaplasty in the Large or Ptotic Breast. Plast Reconstr Surg 2019; 143:1810-1811. [DOI: 10.1097/prs.0000000000005902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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