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Kato S, Mori H, Saiga M, Watanabe S, Sasada S, Sasaki A, Ogiya A, Yamamoto M, Narui K, Takano J, Seki H, Nagura N, Ishitobi M, Shien T. Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan. Breast Cancer 2024; 31:649-658. [PMID: 38589713 DOI: 10.1007/s12282-024-01578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Position of the nipple-areolar complex (NAC) is an important factor in the esthetic impression of the breast, and NAC malposition is often an issue in breast reconstruction after nipple-sparing mastectomy (NSM). The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan). METHODS Patients who underwent unilateral breast reconstruction after NSM at eight hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6-24 months post-operatively. The degree of malpositioning was then statistically compared using various factors. RESULTS The NAC deviated more cranially and medially with implants than that with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition, and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to the degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants. CONCLUSIONS This study provides insights into the tendencies and characteristics of NAC malposition.
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Affiliation(s)
- Sayuri Kato
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan.
| | - Miho Saiga
- Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan
| | - Satoko Watanabe
- Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan
| | - Shinsuke Sasada
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Ayano Sasaki
- Department of Plastic and Reconstructive Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiko Ogiya
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Breast Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Mao Yamamoto
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
- Department of Breast Surgical Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kazutaka Narui
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Junji Takano
- Department of Plastic Surgery, Saitama Medical Center, Saitama, Japan
| | - Hirohito Seki
- Department of Surgery, Saitama Medical Center, Saitama, Japan
- Department of Breast Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Naomi Nagura
- Department of Breast Surgical Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Makoto Ishitobi
- Department of Breast Surgery, Mie University Hospital, Mie, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University Hospital, Okayama, Japan
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Brown CA, Carlson GW. The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis. Ann Plast Surg 2024; 92:379-382. [PMID: 38527341 DOI: 10.1097/sap.0000000000003827] [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: 03/27/2024]
Abstract
INTRODUCTION Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. METHODS We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. RESULTS The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. CONCLUSIONS Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.
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Affiliation(s)
- Ciara A Brown
- From the Division of Plastic Surgery, Emory University School of Medicine, Atlanta GA
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Kurt S, İlgün AS, Özkurt E, Soybir G, Alço G, Ünal Ç, Çelebi FE, Duymaz T, Tapan TK, Ak N, Ordu Ç, Özmen V. Outcomes of reconstructive techniques in breast cancer using BCCT. core software. World J Surg Oncol 2024; 22:82. [PMID: 38519998 PMCID: PMC10960372 DOI: 10.1186/s12957-024-03343-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/14/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Surgery remains a priority for breast cancer treatment. This study aimed to compare the cosmetic outcomes of oncoplastic patients who had undergone breast-conserving surgery, mini-LDF (latissimus dorsi flap), and immediate implant reconstruction using both the Japanese scale and the BCCT.core (The Breast Cancer Conservative Treatment cosmetic results software) program and to validate this program. PATIENTS AND METHODS Patients who underwent surgery for breast cancer between 1997 and 2021 were retrospectively studied. Patients were divided into three groups: 1-those who had undergone breast-conserving surgery (245 patients, 71.3%), 2-those who had undergone mini-LDF after lumpectomy (38 patients, 11.02%), and 3- those who underwent reconstruction with implants after nipple-sparing mastectomy (61 patients, 17.68%). The patients were called for a follow-up examination, and their photos were taken. The photographs were shown to an independent breast surgeon and a plastic surgeon who was not included in the surgeries, and they were asked to evaluate and rate them according to the Japanese cosmetic evaluation scale. The same images were transferred to the computer and scored using BCCT.core. RESULTS The plastic and breast surgeon evaluation results showed no significant difference between the three cosmetic techniques (p = 0.99, 0.98). The results of BCCT.core software measurements were similar to the results of plastic and breast surgeons (p: 0.43). CONCLUSION Patients are more knowledgeable about cosmetic outcomes and expect more objective data. In this study, we used 3 different cosmetic evaluation scales. We found that these techniques give results that are compatible with each other in terms of evaluating the work done in a more concrete way. For this reason, we recommend the use of such software, which offers objective results in a subjective field such as aesthetics and is very easy to apply.
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Affiliation(s)
- Sevgi Kurt
- Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul Florence Nightingale Hospital, Istanbul, Turkey.
| | | | - Enver Özkurt
- Department of General Surgery, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Gürsel Soybir
- Department of General Surgery, Memorial Şişli Hospital, Istanbul, Turkey
| | - Gül Alço
- Department of Radiation Oncology, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Çağlar Ünal
- Division of Medical Oncology, Department of Internal Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | | | - Tomris Duymaz
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Bilgi University, Istanbul, Turkey
| | - Tuğba Kayan Tapan
- Department of Nutrition and Dietetics, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Naziye Ak
- Division of Medical Oncology, Department of Internal Medicine, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Çetin Ordu
- Division of Medical Oncology, Department of Internal Medicine, Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey
| | - Vahit Özmen
- Department of General Surgery, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
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Mercury O, Nores GG, Carlson GW. Symmetry of Nipple Position After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: The Impact of Reconstructive Method. Ann Plast Surg 2022; 88:S422-S426. [PMID: 35690937 DOI: 10.1097/sap.0000000000003162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Asymmetry of nipple position is common in the female population. There are scant data on the impact of bilateral nipple-sparing mastectomy (NSM) and immediate implant-based reconstruction on nipple asymmetry. METHODS A retrospective review was performed of an institutional review board approved prospective database of NSM and immediate implant-based reconstruction was performed. BCCT.core software was used to examine preoperative and postoperative nipple asymmetry. It directly calculates the quantitative differences in nipple position between the breasts expressed as breast retraction assessment (BRA). Nipple to sternal notch (N-SN) asymmetry was calculated from the collected data. RESULTS Sixty-eight patients undergoing bilateral NSM and implant reconstruction were reviewed. Reconstructive methods were tissue expander (TE) 39 (57.4%) and direct to implant (DTI) (prepectoral 13, submuscular 16) 29 (42.6%). The TE group had greater body mass index (BMI) (23.5 vs 22.1, P = 0.02), mastectomy weight (390.7 vs 243.8, P = 0.001) and higher preoperative N-SN asymmetry (TE 0.89 vs DTI 0.59, P = 0.02). Ten patients received radiation (TE group 4, DTI group 6). The TE group had larger implant size (479.1 vs 375.0, P = 0.0001). Overall, TE reconstruction resulted in an increase in nipple asymmetry (mean BRA: preoperative, 1.50 vs postoperative, 1.65), which was not significant. Direct to implant reconstruction increased nipple asymmetry: mean N-SN asymmetry preoperative 0.59 versus postoperative 0.97 (P = 0.04) and mean BRA scores 1.40 and 1.82 (P = 0.06). Both implant locations in the DTI group resulted in an increase in postoperative asymmetry but was significant for the prepectoral group: mean BRA preoperative 1.19 versus postoperative 1.85, P = 0.02 and mean N-SN asymmetry preoperative 0.48 vs postoperative 0.94, P = 0.04. Radiation impacted the final mean BRA score: radiation 2.24 versus no radiation 1.63 (P = 0.05). CONCLUSIONS Patients who underwent TE reconstruction had significantly larger breasts and greater preoperative N-SN asymmetry than the DTI group. Despite this, the TE group resulted in mild increase in nipple asymmetry. Both implant locations in DTI reconstruction resulted in increased postoperative asymmetry but was significant for the prepectoral group. Radiation therapy has a significant impact of nipple asymmetry.
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Affiliation(s)
- Oblaise Mercury
- From the Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta GA
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Nores GG, Carlson GW. The Impact of Tissue Expander Nipple Asymmetry on Final Implant Symmetry After Bilateral Nipple Sparing Mastectomy. Ann Plast Surg 2022; 88:S427-S432. [PMID: 35690938 DOI: 10.1097/sap.0000000000003161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asymmetry of nipple position is common in the female population and very difficult to correct after nipple sparing mastectomy (NSM). There are scant data on the impact of tissue expander (TE) nipple asymmetry on final implant nipple symmetry after bilateral NSM. METHODS A retrospective review of an institutional review board-approved prospective database of NSM and immediate 2-stage implant reconstruction between June 2014 and December 2019 was performed. BCCT.core software was used to examine TE and final implant nipple asymmetry as well as relative breast implant position. Horizontal and/or vertical asymmetry and breast retraction assessment (BRA) were evaluated. Moderate asymmetry was defined as ≥1 cm and severe asymmetry as ≥2 cm. Lower breast contour ≥1 cm defined implant malposition. RESULTS Twenty-three patients met the inclusion criteria. Linear regression analysis showed a significant relationship between TE BRA and final BRA (R2 = 0.2321, P = 0.02) with a mean TE BRA of 2.04 and a mean final BRA of 1.53 (P = 0.05). Tissue expander nipple asymmetry was predictive of final BRA score: no TE asymmetry, 0.87, versus TE nipple asymmetry, 1.67 (P = 0.02). Tissue expander lower breast contour ≥1 cm occurred in 8 patients (36.4%) and was associated with implant nipple asymmetry in 7 (87.5%). The second stage of reconstruction significantly improved the nipple asymmetry in those with TE malposition (TE BRA, 2.34, vs final BRA, 1.67; P = 0.05). Two patients who received radiation had increased BRA scores (radiation, 2.14, vs no radiation, 1.47; P = 0.004). CONCLUSIONS Tissue expander nipple asymmetry as measured by BRA score or nipple asymmetry was predictive of final nipple symmetry. The second stage of TE reconstruction improves the nipple asymmetry. Final implant exchange can allow for pocket and implant manipulation, improving nipple symmetry. Radiation therapy to TE reconstruction has a negative impact on nipple symmetry after the final stage.
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