One-stage nipple and breast reconstruction following areola-sparing mastectomy

Retrospective analysis between complication and nipple areola complex preservation in direct-to-implant breast reconstruction

Background

Since the introduction of skin-sparing mastectomy (SSM), more breast surgeons have been preserving the areola and often nipple areolar complex (NAC) entirely. For better outcomes, more studies are necessary to analyze whether preserving the areola or NAC is unfavorable in breast reconstruction. The aim of this study was to assess the potential risk of areola or NAC preservation in direct-to-implant (DTI) breast reconstruction after SSM.

Methods

We retrospectively reviewed the medical records of patients who underwent immediate breast reconstruction from May 2011 to July 2017. Immediate breast reconstruction was performed with DTI procedure in all cases. In total, 213 breasts met the inclusion criteria and were divided into 3 groups: nipple-sparing mastectomy (NSM), aerola-sparing mastectomy (ASM) which only nipple is excised, and skin-sparing mastectomy (SSM) which whole NAC was excised. Complications including infection, capsular contracture, skin necrosis and explantation were measured.

Results

The mean patient age was 45.3 years, with a range of 27-62 years; the mean follow-up was 3.08 years. NSM, ASM and SSM groups consisted of 121, 30 and 62 breasts, respectively. The Infection rates were statistically lower in SSM group (4.8%) compared with NSM group (15.7%) (P=0.033) but not statistically different from ASM group (13.3%) (P=0.210). SSM group showed significantly lower rate of overall complication compared with both NSM and ASM groups (P=0.005, 0.025 respectively).

Conclusions

Our research suggests that preservation of the NAC increases the rate of infection and skin necrosis in DTI breast reconstruction.

One-stage nipple and breast reconstruction using a deep inferior epigastric perforator flap after a skin-sparing mastectomy

Background

Nipple reconstruction is usually performed as a delayed procedure in patients with breast cancer who undergo skin-sparing mastectomy and breast reconstruction surgery using a deep inferior epigastric perforator (DIEP) flap. The authors designed this study to evaluate the utility of breast reconstruction based on a DIEP flap and immediate nipple reconstruction.

Methods

A retrospective review was conducted of all patients who underwent breast reconstruction performed by a single plastic surgeon from October 2016 to June 2018. Through a questionnaire and chart review, we compared surgical results and complications in cases of single-stage nipple reconstruction after skin-sparing mastectomy (n=17) with patients who underwent delayed nipple reconstruction after skin-sparing mastectomy, modified radical mastectomy, or simple mastectomy (n=7).

Results

In a subjective analysis using clinical photos, the immediate nipple reconstruction group had higher scores than their counterparts in an evaluation of the nipple-areolar complex (NAC) (NAC placement, 3.34 vs. 3.04; nipple projection, 3.05 vs. 3.03; nipple size, 3.30 vs. 3.29). No significant differences between the groups were found in terms of complications.

Conclusions

Simultaneous nipple reconstruction is a reliable surgical method with economic advantages. No differences were found in terms of outcomes and complications in comparison to delayed reconstruction. Therefore, surgeons can consider simultaneous nipple reconstruction without particular concerns about asymmetry or necrosis.

Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi breast reconstruction: A review of patient satisfaction

BACKGROUND

Nipple-areolar complex (NAC) reconstruction following curative mastectomy is traditionally performed as a second-stage procedure several months after initial breast reconstruction. The recent literature has documented the increasing popularity of immediate nipple reconstruction carried out simultaneously during autologous reconstruction. The aim of this study was to evaluate the surgical outcomes and patient satisfaction with immediate breast and nipple reconstruction performed in a single stage after skin-sparing mastectomy.

METHODS

All patients who underwent a skin-sparing mastectomy with immediate latissimus dorsi flap breast and NAC reconstruction as a single-stage procedure from 2007 to 2015 were included. Patient demographics, oncologic details, and surgical outcomes were recorded. The BREAST-Q questionnaire was administered to patients to assess the impact and effectiveness of this reconstructive strategy.

RESULTS

During the study period, 34 breast and NAC reconstructions in 29 patients were performed at Cork University Hospital. The majority of our patient cohort were non-smokers (93.1%) and did not receive adjuvant radiotherapy. Postoperative complications were infrequent, with no cases of partial necrosis or complete loss of the nipple. The response rate to the BREAST-Q was 62% (n=18). Patients reported high levels of satisfaction with the reconstructed breast (62±4), nipple reconstruction (61±4.8), overall outcome (74.3±5), and psychosocial well-being (77.7±3.2).

CONCLUSIONS

Skin-sparing mastectomy with immediate nipple reconstruction during autologous latissimus dorsi reconstruction was demonstrated to be a safe and aesthetically reliable procedure in our cohort, yielding high levels of psychological and physical well-being. A single-stage procedure promotes psychosocial well-being involving issues that are intrinsically linked with breast cancer surgery.

Immediate Nipple Reconstruction During Implant-Based Breast Reconstruction

BACKGROUND

Nipple reconstruction is usually performed as a separate procedure, several months after the primary breast reconstruction. This study compared the outcomes of immediate and delayed nipple reconstructions during implant-based breast reconstructions.

METHODS

A retrospective review was conducted of patients who underwent nipple reconstruction, after implant-based breast reconstruction, between September 2014 and August 2015. The nipple was simultaneously reconstructed following tissue expander removal and implant placement. The reconstructed nipple was evaluated immediately after surgery and 1 year later using objective measurements of nipple dimension and position, and a subjective assessment.

RESULTS

Sixty-one patients were included in the study, undergoing either immediate (n = 37) or delayed (n = 24) nipple reconstructions. Patients undergoing immediate nipple reconstructions had a significantly lower chance of radiotherapy (p = 0.018) and demonstrated a shorter period of tissue expansion (p = 0.011) than those undergoing delayed reconstructions. In the objective evaluations, nipple projections and symmetries between the groups were similar at the 1-year postoperative assessment. In the subjective reviews, esthetic breast mound outcomes were higher among those undergoing immediate reconstructions than among those undergoing delayed reconstructions; similar nipple symmetry and shape outcomes were obtained for both groups.

CONCLUSION

In cases of implant-based breast reconstruction, immediate nipple reconstruction concurrent with breast reconstruction provides satisfactory esthetic results compared with conventional delayed nipple reconstruction, in properly selected patients.

LEVEL OF EVIDENCE IV

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Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction

Background

Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution.

Methods

We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis.

Results

Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery.

Conclusions

NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

Patient-reported outcome measures in reconstructive breast surgery: is there a role for generic measures?

BACKGROUND

Patient-reported outcomes provide an invaluable tool in the assessment of outcomes in plastic surgery. Traditionally, patient-reported outcomes have consisted of either generic or ad hoc measures; however, more recently, there has been interest in formally constructed and validated questionnaires that are specifically designed for a particular patient population. The purpose of this systematic review was to determine whether generic measures still have a role in the evaluation of breast reconstruction outcomes, given the recent popularity and push for use of specific measures.

METHODS

A systematic review was performed to identify all articles using patient-reported outcomes in the assessment of postmastectomy breast reconstruction. Frequency of use was tabulated and the most frequently used tools were assessed for success of use, using criteria described previously by the Medical Outcomes Trust.

RESULTS

To date, the most frequently used measures are still generic measures. The 36-Item Short-Form Health Survey was the most frequently used and most successfully applied showing evidence of responsiveness in multiple settings. Other measures such as the Hospital Anxiety and Depression Scale, the Hopwood Body Image Scale, and the Rosenberg Self-Esteem Scale were able to show responsiveness in certain settings but lacked evidence as universal tools for the assessment of outcomes in reconstructive breast surgery.

CONCLUSIONS

Despite the recent advent of measures designed specifically to assess patient-reported outcomes in the breast reconstruction population, there still appears to be a role for the use of generic instruments. Many of these tools would benefit from undergoing formal validation in the breast reconstruction population.