Inframammary approach to nipple-areola-sparing mastectomy. Plast Reconstr Surg. 2013;132:700e-708e. [PMID: 24165622 DOI: 10.1097/prs.0b013e3182a4d64f]

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of surgical variables on residual glandular tissue in risk-reducing mastectomies: Results of a retrospective monocentric study from a center of the German consortium for hereditary breast and ovarian cancer

PURPOSE

Residual glandular tissue (RGT) after risk reducing mastectomy (RRME) is associated with a risk of developing breast cancer for women with a familial predisposition. We aim to examine various surgery-related variables to make risk more easily assessable and to aid in decision-making.

MATERIALS AND METHODS

Pre- and postoperative breast MRI scans from 2006 to 2021 of patients with proven pathogenic mutation were included. The postoperative remaining skin flap was recorded using distance measurements at 8 equally distributed clockwise points and retromamillary. Each breast was volumetrized, as well as existing RGT. Patient-related covariates were further recorded and their influence on RGT was investigated uni- and multivariately.

RESULTS

81 patients (49 with BRCA1, 24 with BRCA2, 9 with other mutations), who were on average 39 years old, had 117 breasts analyzed. The mean follow-up was 71 months. In multivariate analysis, the independent variable skin flap thickness had a positive effect (p ≤ 0.01), while surgeon experience negatively affected RGT (p ≤ 0.05). The incision type was found to impact RGT as well, with nipple-sparing mastectomy (NSM) with inframammary fold incision leading to more RGT (p ≤ 0.01 - p ≤ 0.05), and skin-sparing mastectomy (SSM) with an inverted T incision leading to less (p ≤ 0.01).

CONCLUSION

Different surgical variables have an impact on postoperative RGT, which is an important tool to quantify the risk of developing breast cancer after RRME. In order to effectively consider these variables in future preoperative/intraoperative management, they must be carefully taken into account.

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.

Prophylactic nipple-sparing mastectomy with immediate breast reconstruction: results of a French prospective trial

BACKGROUND

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) is used increasingly when performing a prophylactic mastectomy. Few prospective studies have reported on complication rates. This complementary trial to the French prospective multicentre MAPAM trial aimed to evaluate the nipple-areola complex (NAC) necrosis rate in prophylactic NSM with IBR.

METHODS

Patient characteristics and surgical data were recorded. Morbidity after prophylactic NSM with a focus on NAC necrosis was analysed.

RESULTS

Among 59 women undergoing prophylactic NSM, 19 (32 per cent) of the incisions were partly on the NAC. Reconstructions were performed with 46 definitive implants and 13 expanders. The crude rate of postoperative complications was 25 per cent (15 patients). Complete NAC necrosis was reported in two women (3 per cent) and partial or total necrosis in nine (15 per cent). No NAC resection was necessary. Median BMI was lower in women with total or partial NAC necrosis compared with the others (20.0 versus 21.3 kg/m2 respectively; P = 0.034).

CONCLUSION

Results of this prospective study confirm that prophylactic NSM with IBR is associated with a low risk of total NAC necrosis.

Pure hemi-periareolar incision versus conventional lateral radial incision mastectomy and direct-to-implant breast reconstructions: comparison of indocyanine green angiographic perfusion and necrosis of the nipple

Background

This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap.

Methods

Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes.

Results

A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P<0.001). No nipple perfusion pattern was a significant predictor for nipple-areola complex necrosis in univariable and multivariable analyses (P<0.001). There was no case of reconstruction failure.

Conclusions

Immediate direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision can be safely performed using indocyanine green angiographic evaluation on the mastectomy skin flap.

Inframammary Fold Incision Can Reduce Skin Flap Necrosis in Immediate Breast Reconstruction With Implant and Conjoined Fascial Flap

BACKGROUND

Immediate breast reconstruction with implant (IBRI) can produce good aesthetic results after nipple-sparing mastectomy (NSM). Various surgical incisions can be used for NSM. The purpose of this study is to compare outcomes of using an IBRI with dual-coverage fascial flap after NSM with an inframammary fold (IMF) or a radial (Rd) incision.

METHODS

We retrospectively reviewed the records of 88 women who underwent IBRI with dual-coverage fascial flap from March 2015 to June 2018. Inframammary fold incision was used in 19 patients (22 breasts) and Rd incision in 69 patients (75 breasts). In the dual-coverage method, acellular dermal matrix covered the inferomedial quadrant of the breast, and conjoined fascial flap covered the remaining inferolateral quadrant. Patient-reported satisfaction was assessed using the Breast-Q questionnaire, and plastic surgeons assessed aesthetic postoperative scores.

RESULTS

Complications and reoperation rates of 2 incisions were as follows: skin flap necrosis rate showed significant difference between 2 groups (IMF, 0.0% [0/22]; Rd, 16.0% [12/75]; P < 0.05). The other complication rates, hematoma, seroma, infection, capsular contracture, and total reoperations showed no significant difference. Postoperative Breast-Q scores were higher in the IMF group (331.9 ± 10.1) than in the Rd group (311.4 ± 11.0; P < 0.05), indicating higher satisfactory rate in the IMF group than in the Rd group. Surgeon-reported scores for breast symmetry, contour, and scar appearance were also higher in the IMF group (P < 0.05).

CONCLUSIONS

Immediate breast reconstruction with implant with dual-coverage fascial flap after NSM with IMF incision was associated with a lower rate of postoperative skin flap necrosis and improved patient satisfaction, compared with Rd incision. Inframammary fold incisions were associated with improved scar and breast appearance.

Oncoplastic Breast Consortium consensus conference on nipple-sparing mastectomy

Purpose

Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion.

Methods

The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology.

Results

Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference.

Conclusions

In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4937-1) contains supplementary material, which is available to authorized users.

Comparison of Outcomes between Direct-to-Implant Breast Reconstruction Following Nipple-Sparing Mastectomy through Inframammary Fold Incision versus Noninframammary Fold Incision

Purpose

In properly selected patients with breast cancer, nipple-sparing mastectomy (NSM) is generally considered safe by oncologic standards. We examined two groups of patients who underwent direct-to-implant (DTI) reconstruction after NSM, comparing complications encountered, revision rates, and aesthetic outcomes. The patients were stratified based on type of surgical incision and assigned to inframammary fold (IMF) and non-IMF groups.

Methods

We investigated 141 patients (145 breasts) subjected to NSM and immediate DTI reconstruction between 2013 and 2016. A total of 62 breasts (in 58 patients) were surgically removed via IMF incisions, with the other 83 breasts (in 83 patients) removed by non-IMF means.

Results

Complications associated with IMF (n=62) and non-IMF (n=83) incisions were as follows: skin necrosis (IMF, 9; non-IMF, 18); hematoma (IMF, 3; non-IMF, 4); seroma (IMF, 8; non-IMF, 4); mild capsular contracture (IMF, 4; non-IMF, 7); and tumor recurrence (IMF, 2; non-IMF, 8). Surgical revisions were counted as duplicates (IMF, 18; non-IMF, 38). Aesthetic outcomes following IMF incisions were rated as very good (44.2%), good (23.1%), fair (23.1%), or poor (9.6%).

Conclusion

IMF incision enables complete preservation of the nipple-areolar complex, yielding superior aesthetic results in immediate DTI breast reconstruction after NSM. The nature of incision used had no significant impact on postoperative complications or reoperation rates and had comparable oncologic safety to that of non-IMF incisions. IMF incisions produced the least visible scarring and did not affect breast shape. Most patients were satisfied with the aesthetic outcomes.

Nipple sparing mastectomy techniques: a literature review and an inframammary technique

Nipple sparing mastectomy (NSM) has quickly become an accepted technique for patients with selected cancers and for risk reducing surgery. Much of its surgical acceptance over the last decade has been based on the low risk of nipple areolar complex (NAC) occurrence in breast cancer patients. Improved patient satisfaction due to improved cosmetic outcomes with reconstruction have also driven its popularity. We reviewed current English journals to determine the NSM techniques which achieve the lowest complications, best outcomes, and best patient satisfaction. We researched studies showing reductions in complications with improved surgical techniques and patient selection which have been implicated in improved results. In the studies reviewed, incision placement, away from the nipple, resulted in the lowest rates of ischemic nipple complications and the best cosmetic outcomes. The effect of other factors such as surgeon experience and thickness of skin flap development were more difficult to prove. Leaving a 2-3 mm rim of tissue around the nipple bundle was shown to help preserve the nipple vascularity. Lower complication rates with improved outcomes and patient satisfaction were reported in the literature in patients with B or smaller cup sizes, non-smokers, and patients with lower body mass index (BMI). Incision placement, away from the nipple, with preservation of a 2-3 mm rim of tissue around the nipple bundle along with careful patient selection were the most significant variables reviewed which helped to lower complications rates of NSM. Coordinated surgical planning with the breast and plastic surgeons to determine the best surgical approach for each individual patient is necessary to obtain the best results. Although short-term oncologic follow-up seems to be acceptable, longer follow-up will still be needed to define the best breast cancer surgical candidates for the nipple sparing approach.

Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry

Background

The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM).

Methods

Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR.

Results

This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery.

Conclusions

NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.

Staged Suprapectoral Expander/Implant Reconstruction without Acellular Dermal Matrix following Nipple-Sparing Mastectomy

BACKGROUND

Since the introduction of nipple-sparing mastectomy as an oncologically safe procedure for the treatment of breast cancer, reconstructive efforts for immediate staged expander/implant reconstruction have focused on submuscular implantation with or without acellular dermal matrix. Suprapectoral reconstruction without acellular dermal matrix has received little attention in the reconstructive literature of nipple-sparing mastectomy.

METHODS

Between 2005 and 2015, 155 patients (250 breasts) underwent nipple-sparing mastectomy with prepectoral staged expander/implant reconstruction using thick mastectomy skin flaps without acellular dermal matrix. Patients with different breast sizes, including those patients with very large breasts who required a primary mastopexy, were considered candidates for the suprapectoral reconstruction. Tumor-related data, comorbidities, and preoperative or postoperative radiation therapy were evaluated for correlation with the final outcome.

RESULTS

Patients were followed up for an average of 55.5 months (range, 138.1 to 23.6 months). The tumor recurrence rate was 2.6 percent. Adverse outcomes such as capsular contracture, implant dystopia, and rippling were studied. Aesthetic outcome, based on a three-point evaluation scale, showed 53.6 percent of patients as having a very good result, 31.6 percent showing a good result, 9 percent showing a fair result, and 5.8 percent showing a poor result.

CONCLUSIONS

The suprapectoral two-stage expander/implant reconstruction without acellular dermal matrix in nipple-sparing mastectomy has certain advantages with respect to breast shape, less morbidity related to expansion, ease of reconstruction, and cost effectiveness. These advantages have to be weighed against those of subpectoral reconstruction with acellular dermal matrix to determine the method of choice.

CLINCAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Impact of Acellular Dermal Matrix (ADM) Use Under Mastectomy Flap Necrosis on Perioperative Outcomes of Prosthetic Breast Reconstruction

BACKGROUND

There is conflicting data on the potential necrotic complications of acellular dermal matrix (ADM) use in breast reconstruction, and most studies focus on mastectomy flap necrosis as an outcome measure associated with ADM use. The aim of this study was to examine cases with necrotic complications with and without the use of ADM and to investigate whether ADM affected perioperative outcomes in cases with necrotic complications.

METHODS

Patients who experienced mastectomy flap necrosis following mastectomy with tissue expander placement between January 2009 and March 2015 were retrospectively reviewed. The primary outcome was explantation of the expander, and other associated outcomes such as seroma or infection were also recorded.

RESULTS

A total of 57 breasts with mastectomy flap necrosis were identified: 32 of which were in the non-ADM group and 25 in the ADM group. The rate of explantation was 28% (7/25) in the ADM group versus 6.3% (2/32) in the non-ADM group, which was significantly different (P = 0.034). The ADM group had a significantly higher rate of "major" infection requiring surgical debridement than the non-ADM group (P = 0.016). Multivariate analysis showed that the use of ADM was trending toward an increasing expander rate with borderline significance (P = 0.05).

CONCLUSION

This study demonstrated that ADM use under mastectomy flap necrosis was a potential risk for explantation of the expander and major infection. Surgeons should be cautious with the use of ADM with devascularized mastectomy skin flaps prone to necrosis.

LEVEL OF EVIDENCE III

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 .

Breast-conserving surgery using an inframammary fold incision technique for breast cancer

BACKGROUND

Breast-conserving surgery is an established alternative for the majority of women with early stage breast cancer. Consensus on negative margins (no ink on tumour) for invasive cancer makes mutilating extensive lumpectomies unnecessary. Several breast-conserving surgical methods are described in the literature. The aim of this study was to describe and evaluate a technique using the inframammary fold incision.

METHODS

Twenty-seven patients with suspected breast cancer (stage I-II) underwent breast-conserving surgery using the inframammary fold incision. Data regarding tumour characteristics, margin status, complications, oncologic and aesthetic outcome was analysed retrospectively.

RESULTS

After a median follow-up of 35 months, 23 of the 24 patients with breast cancer (95.8%) had no evidence of disease. Post-operative complications (as defined by infection requiring antibiotic treatment and/or seroma requiring drainage) were seen in three of the 27 patients (11.1%). The final pathological examination revealed a positive excision margin in four patients (16.7%). Post-operative evaluation with the BREAST-Q™ BCT module showed a mean RASCH score of 72.5 regarding 'Satisfaction with breast'. The aesthetic result with a hidden scar is exemplified.

CONCLUSION

Breast-conserving surgery using the inframammary fold incision seems to be a safe method with better cosmesis; however, further research is needed.

Expanded Indications and Improved Outcomes for Nipple-Sparing Mastectomy Over Time

BACKGROUND

Demand for nipple-sparing mastectomy (NSM) has increased. The authors' initial NSM guidelines included risk reduction and cancers 2 cm or smaller located more than 2 cm from the nipple. The relative contraindications included obesity, large and/or ptotic breasts, and prior radiation. This study aimed to evaluate changes over time in NSM indications, surgical approach, and early outcomes.

METHODS

After institutional review board approval, the study identified 354 patients scheduled for 588 NSMs, 341 (96%) of whom underwent 566 NSMs. Changes across time [early (2009-2010), mid (2011-2012), and recent (2013-6/2014)] were assessed using tests for linear trend.

RESULTS

For patients undergoing reconstruction, NSMs increased from 24% (early) to 40% (recent) (p = 0.004). Among the NSM patients, average body mass index, proportion with bra cup sizes of C or larger, and prior radiation increased significantly over time. Performance of NSM for tumors 2 cm or less from the nipple increased from 5 to 18%, and after neoadjuvant therapy, from 8 to 21.5% (p = 0.02). Use of inframammary, radial, and reduction-type incisions increased over time, together with intraoperative laser angiography (both p < 0.0001). Concomitantly, the overall complication rate, complications requiring treatment, and postoperative nipple loss decreased. During a median follow-up period of 19 months, five locoregional recurrences (LRR) were observed, for an estimated 2-year LRR rate of 1.7% [95% confidence interval (CI), 0-3.9%].

CONCLUSIONS

Over time, the indications for NSM expanded in terms of patient characteristics, tumor stage, and prior therapy, whereas the complication rates decreased. Excellent short-term outcomes suggest that NSM is a reasonable approach for many risk-reduction and cancer patients without disease in the nipple-areolar complex. Further study is needed to assess long-term aesthetics, patient satisfaction, and oncologic safety.

Nipple-sparing mastectomy in breast cancer patients: The role of adjuvant radiotherapy (Review)

The present study aimed to evaluate the role of adjuvant radiotherapy (RT) following nipple-sparing mastectomy (NSM) for patients with ductal carcinoma in situ and invasive breast cancer, based on the published literature. Currently, there is no standard for RT following NSM. NSM aims to spare the nipple areola complex (NAC) without compromising locoregional control. Long-term follow-up studies have begun to show promising results. A search of the English literature was performed using the Medline database and Cochrane central library, with the keywords 'nipple/areola-sparing mastectomy', 'whole skin mastectomy' and 'NAC preservation'. A total of 32 original studies with data on NSM in terms of locoregional control, NAC control, NAC necrosis and adjuvant RT were identified. The median locoregional and NAC recurrence rates were 3.2 and 1.4% (range, 0-28.4% and 0-3.7%), respectively. The volume of remaining breast tissue following NSM was reported inconsistently. In 15 studies, RT was not mentioned. In the remaining 17 studies, RT was administered in 0-100% of patients. Only 7 studies provided detailed information regarding the use of adjuvant RT. Adjuvant thoracic wall irradiation was not used in certain studies, not even for locoregionally advanced tumors. Overall, NSM appears a feasible treatment without increased risk of locoregional recurrence for selected patients. The role of adjuvant RT following NSM requires further clarification. The decision regarding adjuvant RT must be made in interdisciplinary tumor boards and with consideration of the individual situation of the patient.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.

Advanced locoregional therapies in breast

BACKGROUND

Advanced locoregional therapies continue to advance the treatment of breast cancer. These techniques are geared towards optimizing oncologic and aesthetic outcome as well as decreasing and treating morbidity. We present a selection of specialized locoregional therapies dedicated to the optimization of breast cancer treatment.

METHODS

Locoregional therapies for breast cancer are presented to address breast conservation techniques, lipofilling techniques, reconstruction techniques for nipple-sparing mastectomy, re-irradiating the breast, axillary reverse mapping, and vascularized lymph node transfer.

RESULTS

We present a synopsis of identified breast locoregional therapies targeted to address optimal oncologic and aesthetic outcome as well as decrease and treat morbidity.