Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis

BACKGROUND

The surgical goals of gender reassignment surgery of the breast in female-to male transsexuals (FMT) is the aesthetic shaping of a male thoracic wall with minimal scarring, while preserving the sensitivity of the nipple-areola complex (NAC). For large and ptotic breasts, we perform a mastectomy over an inframammary access with inferior pedicled NAC under color Doppler visualization of the perforators. This paper presents the technique, including complications and assessment of quality of life, as part of a unicentric analysis.

METHODS

This was a retrospective analysis of 23 patients (46 mastectomies) performed between September 2014 and September 2020. The complication rate and the number of corrective surgeries were recorded for quality assessment. A semiquantitative score was used to evaluate aesthetic outcome, nipple sensitivity, quality of life, and sexuality.

RESULTS

A total of 46 mastectomies were performed in 23 patients. The patient survey showed high patient satisfaction. Loss of nipple sensitivity was observed after one mastectomy (2.17%). In 91.67% of cases, patients reported that their appearance reflected how they feel on the inside. In 75% of cases, patients reported feeling equal to other men. The overall complication rate was 10.87%. Shape correction due to persistent excess of volume was rare (2.17%, equivalent to one mastectomy).

CONCLUSION

Subcutaneous mastectomy with inferior nipple pedicle can be performed with a high degree of safety and satisfaction in FMT. Color Doppler-guided visualization of the perforator vessels is helpful in allowing a thin pedicle preparation, thus reducing the need for secondary surgeries to optimize the shape.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Usefulness of cordless ultrasonic cutting energy devices in endoscopic nipple-sparing mastectomy: a retrospective study

Purpose

Endoscopic nipple-sparing mastectomy (E-NSM) is a minimally invasive surgical technique that shows good results in patients with breast cancer. The authors compared 3 different types of commercial energy devices to examine their efficacy and safety in E-NSM performed with breast reconstruction.

Methods

A total of 36 cases of E-NSM were conducted with either Sonicision (S group, n = 11), Harmonic (H group, n = 6), or Thunderbeat (T group, n = 19). The clinicopathologic factors and postoperative complications, including nipple or skin necrosis and surgical site seroma volume, were evaluated for 3 months after surgery.

Results

The surgical duration of E-NSM was significantly shorter in the S group than in the H group (P = 0.043) and T group (P = 0.037). However, the total surgical duration including E-NSM and breast reconstruction, and the total and daily drainage volume of postoperative seroma did not differ significantly among the 3 groups. Even when the energy devices were compared according to their working principle, i.e., ultrasonic (S and H) vs. hybrid (T), the total breast surgery duration and total and daily drainage volume of seroma showed no difference between the 2 groups. Although surgeon satisfaction did not significantly differ when using 3 devices for E-NSM (P = 0.428), surgeon's fatigue was found to be lowest in the S group, though it was not significant (P = 0.064).

Conclusion

Any energy device can be safely used for E-NSM with breast reconstruction without causing any major complications. However, cordless ultrasonic energy devices allow greater mobility for the surgeon and, therefore, may shorten surgical time in breast surgery.

Early experience of robotic axillary lymph node dissection in patients with node-positive breast cancer

BACKGROUND

Robotic surgical systems enable surgeons to perform precise movement in the surgical field using high-resolution 3D vision and flexible robotic instruments. We aimed to evaluate the feasibility and safety of performing axillary lymph node dissection using a robotic surgical system in patients with node-positive breast cancer.

METHODS

Thirty-two women with breast cancer who underwent robot-assisted nipple-sparing mastectomy (RNSM) and level I/II axillary lymph node dissection were analyzed. Patients were divided into two groups: RNSM with conventional axillary lymph node dissection (CALND) vs. RNSM with robotic axillary lymph node dissection (RALND). Clinicopathological features and surgical outcomes were analyzed.

RESULTS

The median age of the patients was 44 (range 20-59) years. Eleven patients underwent RALND. None of the clinicopathologic features differed between the two groups. There were no statistically significant differences in surgical outcomes, except for the final incision size, between the two groups. The proportion of cases with an incision ≤ 40 mm was 63.6% in the RALND group and 36.4% in the CALND group (p = 0.020).

CONCLUSION

RALND can be safely performed in RNSM. RNSM with RALND is comparable to RNSM with CALND in terms of early surgical outcomes. The incision size can be reduced when using RALND.

Masculinizing and defeminizing gender-affirming surgery

Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.

Endoscope-Assisted Minimally Invasive Surgery for the Treatment of Glandular Gynecomastia

BACKGROUND

Gynecomastia (GYN) is the most common benign disease in males. A vacuum-assisted biopsy is a minimally invasive surgical technique for GYN treatment that achieves satisfactory aesthetic results. However, due to the operation under non-direct vision, it is difficult to localize the bleeding points and assess the residual glandular tissue. Endoscopy was applied to observe the operative field after subcutaneous mastectomy. The present study aimed to recommend our initial experience in glandular GYN with endoscope-assisted minimally invasive subcutaneous mastectomy.

METHODS

A total of 34 patients diagnosed with glandular GYN (50 breasts), treated with endoscope-assisted minimally invasive surgery at The First Affiliated Hospital with Nanjing Medical University between June 2018 and June 2020, were enrolled in this study. According to Simon's classification of the breast, 10 was grade I, 25 was grade IIA, and 15 was grade IIB. The characteristics of patients, operative data, postoperative complications, cosmetic outcome, and patient satisfaction were recorded.

RESULTS

Endoscope-assisted minimally invasive mastectomy was performed successfully in all cases. The operative duration of the operation was 55-120 min/side. The total weight of the resected tissue of the 50 breasts was 55-350 g, and the blood loss was 10-105 mL/breast. Endoscopy detected five breasts with bleeding and three with residual glandular during the operation. Postoperative bleeding occurred in 1 breast, subcutaneous seroma in 3 breasts, dysesthesia of the nipple-areolar complex in 2 breasts, and skin redundancy in a bilateral patient. None of the patients experienced severe pain, infection, nipple necrosis, and nipple retraction, a saucer-like deformity. With a median follow-up of 21 months, all patients were satisfied with their cosmetic outcome (100%), and no recurrence occurred.

CONCLUSION

Endoscope-assisted minimally invasive mastectomy could be used as a feasible technique for the treatment of glandular GYN.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online. Instructions to Authors www.springer.com/00266 .

Expected Reduction of The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone

BACKGROUND

The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia.

OBJECTIVE

The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL).

MATERIALS AND METHODS

A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed.

RESULTS

The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=<0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cm² (SD 1.48) or 23.37% (SD 9.78) after 5.82 years and in the SCM+UAL cohort 2.60cm² (SD 1.60) or 35.85% (SD 6,86) after 7.43 years. As independent significant factors for reduction of the NAC, the resection weight and SCM+UAL combination were identified. There were no significant differences regarding the patients' satisfaction measured with the BODY-Q (p=0.222) and the ordinal scale (p=0.445) between the two cohorts.

CONCLUSIONS

The SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Occurrence of Residual Cancer Within Re-excisions After Subcutaneous Mastectomy of Invasive Breast Cancer and Ductal Carcinoma In Situ - A Retrospective Analysis

BACKGROUND/AIM

Surgical margin status remains an important determinant for recurrence of invasive breast cancer and ductal carcinoma in situ. We compared the number of positive margins in initial histology with rates of residual tumor in re-excision specimens. Furthermore, we analysed cost-effectiveness of re-excisions.

PATIENTS AND METHODS

101 patients treated with secondary surgery were included. The first group underwent breast conserving surgery and secondary mastectomy. The second group was primarily treated with subcutaneous mastectomy followed by secondary surgery.

RESULTS

Within the first group, 22.7% did not show residual tumor in the re-excision specimen. Of the second group, 54.3% had no residual tumor. Consequentially 45.7% needed a re-excision to achieve R0 status. Cost-effectiveness was determined as secondary endpoint. If a patient needs a secondary mastectomy the hospital gains 602,65€ in comparison to a primary breast conserving operation.

CONCLUSION

In every second patient who had first received a subcutaneous mastectomy, no tumor could be detected in the secondary operation despite a previous R1 status.

Comparison of breast cancer patients who underwent partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (M + I) regarding quality of life (QOL), cosmetic outcome and survival rates

PURPOSE

The latissimus dorsi muscle has long been used in breast cancer (BC) patients for reconstruction. This study aimed to compare early stage BC patients who had partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (MI) with respect to quality of life (QoL), cosmetic outcome (CO), and survival rates.

PATIENTS AND METHODS

The data of patients who underwent PM + MLDF (Group 1) and M + I (Group 2) between January 2010 and January 2018 were evaluated. Both groups were compared in terms of demographics, clinical and pathological characteristics, surgical morbidity, survival, quality of life, and cosmetic results. The EORTC-QLQ C30 and EORTC-QLO BR23 questionnaires and the Japanese Breast Cancer Society (JBCS) Cosmetic Evaluation Scale were used to assess the quality of life and the cosmetic outcome, respectively.

RESULTS

A total of 317 patients were included in the study, 242 (76.3%) of them in group 1 and 75 (23.6%) of them in group 2. Median follow-up time was 56 (14-116) months. There were no differences identified between the groups in terms of tumor histology, hormonal receptors and HER-2 positivity, surgical morbidity, and 5-year overall and disease-free survival. Group 2 patients were significantly younger than group 1 (p = 0.003). The multifocality/multicentricity rate was higher in group 2 (p ≤ 0.001), whereas tumor size (p = 0.009), body mass index (BMI, p = 0.006), histological grade (p ≤ 0.001), lymph node positivity (p = 0.002), axillary lymph node dissection (ALND) rate (p = 0.005), and presence of lympho-vascular invasion (LVI, p = 0.013) were significantly higher in group 1. When the quality of life was assessed by using the EORTC QLQ C30 and BR23 questionnaires, it was seen that the body image perception (p < 0.001) and nausea/vomiting score (p = 0.024) were significantly better in PM + MLDF group whereas physical function score was significantly better in M + I group (p = 0.012). When both groups were examined in terms of cosmesis with JBCS Cosmetic Evaluation Scale, good cosmetic evaluation score was significantly higher in patients in MLDF group (p = 0.01).

DISCUSSION

The results of this study indicate that in comparison to M + I procedure, the PM + MLDF procedure provides significantly superior results in terms of body image and cosmetic result with similar morbidity and oncologic outcomes. In selected patients with small breasts and a high tumor/breast ratio, PM + MLDF may be an alternative to subcutaneous mastectomy and implant.

Risk-reducing mastectomy: a case series of 124 procedures in Brazilian patients

PURPOSE

Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy, however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncological safety of nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates, and unfavorable events of 62 Brazilian patients that underwent risk-reducing NSM from 2004 to 2018.

METHODS

Patient data were reviewed retrospectively and descriptive statistics were utilized to summarize the findings.

RESULTS

The mean patients age was 43.8 years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications had occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50 months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM.

CONCLUSIONS

Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncological outcomes and low complication rates in a case series of Brazilian patients.

Nipple-sparing mastectomy through periareolar incision with immediate reconstruction

Purpose

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

Methods

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

Results

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

Conclusion

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

Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast

Nipple-areolar skin-sparing mastectomy followed by autologous reconstruction in patients with large, ptotic breasts often offers a limited field, resulting in strenuous traction. Skin-sparing mastectomy (SSM) with immediate nipple grafting from the specimen was attempted for such patients. Patients who underwent SSM with immediate autologous breast reconstruction and nipple grafting between September 2016 and February 2019 were evaluated, including 33 nipple grafts in 30 patients. The average weight of the mastectomy specimen was 552.5 g and the average operation time for unilateral mastectomy was 109 minutes. No complete nipple loss or major skin flap necrosis was reported. Adjuvant therapy started after an average of 24 days. SSM with immediate nipple grafting on the autologously reconstructed breast could be an alternative for large, ptotic breasts. It is also useful for patients requiring contralateral balancing procedures or those with bilateral breast cancer in which only one nipple can be spared oncologically.

Oncologic Outcomes of Nipple-Sparing Mastectomy with Immediate Breast Reconstruction in Patients with Tumor-Nipple Distance Less than 2.0 cm

Purpose

Although the indications for nipple-sparing mastectomy (NSM) are expanding, there remains a debate regarding the oncologic outcomes of patients treated with this method, especially those with a short tumor–nipple distance (STND). The aim of this study was to compare the long-term oncologic outcomes between patients with a long tumor–nipple distance (LTND) (≥ 2.0 cm) and those with STND (< 2.0 cm).

Methods

This was a retrospective study in which 266 patients who underwent NSM with immediate breast reconstruction between January 2008 and December 2014 at a single institution were enrolled. Of these patients, 21 were excluded because of loss to follow-up; thus, 245 patients were finally analyzed. All patients underwent preoperative breast magnetic resonance imaging and intraoperative frozen biopsy.

Results

The mean age of the patients was 42.4 years. STND was identified in 128 patients, and LTND in 117 patients. The mean follow-up period was 60.5 months. There were no significant differences between the 2 groups with respect to lymphovascular invasion, nuclear grade, nodal status, and subtype (p = 0.339, 0.372, 0.955, and 0.338, respectively). The STND group had significantly smaller tumors than the LTND group (p = 0.005). The median TND in the STND and LTND groups was 0.7 cm and 3.0 cm, respectively. Locoregional recurrence was reported in 4 patients in the STND group (3.1%) and 6 (5.1%) in the LTND group. A total of 3 patients died (1.2%; 2 in the STND group and one in the LTND group). There was no significant difference between the 2 groups with respect to disease-free survival or local recurrence-free survival (p = 0.334 and p = 0.477, respectively).

Conclusion

The long-term oncologic outcomes of patients treated with NSM did not significantly differ according to TND when the intraoperative frozen biopsy was negative for tumor cells.

The Characteristics and Short-Term Surgical Outcomes of Adolescent Gynecomastia

BACKGROUND

Most adolescent gynecomastia is resolved spontaneously in 3 years. But, persistent gynecomastia could have a negative influence on psychoemotional development on adolescence. The purpose of this study is to report the characteristics of adolescent gynecomastia patients who received the surgeries, and discuss the short-term surgical outcomes.

METHODS

Of the 1454 patients who underwent gynecomastia surgery at Damsoyu hospital from January 2014 to May 2016, 71 were adolescents. Subcutaneous mastectomy with liposuction was performed for adolescent patients who had gynecomastia for more than 3 years and showed psychosocial distress. Demographic and outcome variables were retrospectively analyzed.

RESULTS

The mean age was 17.5 ± 0.77 years old. All gynecomastia cases were bilateral. Simon's grade IIa (35 patients, 49.3%) was the most common, and grade III was not observed. Fifty-one patients (71.8%) were classified as having a glandular-type breast component. Fourteen patients (19.7%) had complications, but only 3 cases (4.2%) required revision. Most of the patients (70 patients, 98.6%) were satisfied with the esthetic results, and the average 5-point Likert score was 4.85 ± 0.40. Recurrence was not observed. As the Simon's grade increased from I to IIA, a higher BMI, larger amounts of breast tissue, and longer operation times were observed.

CONCLUSIONS

Gynecomastia that did not regress spontaneously was mostly the glandular type, so not only liposuction but also surgical removal of glandular tissue is necessary. Surgical treatment, selectively performed in patients who have had gynecomastia for 3 years, and have experienced psychosocial distress, could be an acceptable treatment for adolescent gynecomastia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Surgical Management of Gynecomastia: Subcutaneous Mastectomy and Liposuction

BACKGROUND

The treatment of gynecomastia depends on multiple factors, and the best modality is controversial. In this study, we aimed to determine the best management approach by comparing outcomes of two groups of patients with gynecomastia who received subcutaneous mastectomy combined with liposuction and liposuction only.

METHODS

We conducted a retrospective analysis of 64 patients who underwent surgery for gynecomastia. We divided the patients into two groups: group A, patients who underwent liposuction only; and group B, patients who underwent liposuction and subcutaneous mastectomy. The serial photographs of all patients were clinically evaluated with respect to size, shape, scarring, and overall outcome by three plastic surgeons, and patient satisfaction was surveyed with regard to palpable lumps, size, shape, scarring, and overall outcome.

RESULTS

Of the 64 subjects, 16 received liposuction only, and 48 received the combination procedure. A total of 125 breasts were involved. The doctors' scores for size and overall outcome were significantly better in the combination group, whereas scarring was better in the liposuction-only group. Similarly, patient satisfaction regarding size was significantly higher in the combination group, and satisfaction regarding scarring was significantly higher in the liposuction-only group. The scores for scarring in the combination treatment group were acceptable.

CONCLUSION

Our study shows that combination treatment with liposuction and subcutaneous mastectomy results in satisfactory outcomes, including the extent of scarring. We conclude that this combination treatment should be recommended as the standard surgical treatment for gynecomastia and can provide excellent results in cases where glandular tissue needs to be removed.

LEVEL OF EVIDENCE V

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 .

Oncologic Safety of Immediate Breast Reconstruction in Breast Cancer Patients Who Underwent Neoadjuvant Chemotherapy: Short-Term Outcomes of a Matched Case-Control Study

INTRODUCTION

Although the indication for immediate breast reconstruction (IBR) after skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) has been expanded, IBR after neoadjuvant chemotherapy (NACT) is still controversial. We conducted retrospective matched case-control study to analyze oncologic outcomes between patients who underwent TM only and those who underwent IBR after SSM or NSM after NACT.

PATIENTS AND METHODS

A retrospective review of breast cancer patients who underwent IBR after SSM or NSM after NACT between 2008 and 2015 at a single center was conducted. These cases were maximally matched by 1:5 to patients who underwent total mastectomy (TM) alone after NACT. Matching variables included age, clinical T and N stage before NACT, response to NACT, and pathologic stage after NACT. Pathologic stage followed the 7th edition of the American Joint Committee on Cancer (AJCC) classification.

RESULTS

Overall, 31 patients were enrolled onto the IBR after SSM or NSM group (study group) and matched to 85 patients (control group). In the study group, 13 patients (41.9%) underwent NSM and 18 (58.1%) underwent SSM. Median follow-up duration was 29.2 (range, 7-31) and 38.8 (range, 11-85) months for the study and control groups (P = .012), respectively, and median age was 37.0 (range, 26-57) and 40.0 (range, 24-56) years (P = .890), respectively. Overall survival (P = .971), disease-free survival (P = .520), distant metastasis-free survival (P = .795), and local recurrence-free survival (P = .628) did not differ significantly between the 2 groups.

CONCLUSION

IBR after SSM or NSM might be a feasible surgical treatment option even in breast cancer patients who underwent NACT.

Experience with Bilateral Risk-Reducing Mastectomy for an Unaffected BRCA Mutation Carrier

Women with BRCA1/2 mutations have a high risk of breast cancer and may opt for risk-reducing mastectomy (RRM). We report a 38-year-old Japanese woman who was diagnosed as a BRCA2 mutation carrier. She underwent prophylactic bilateral skin-sparing mastectomy (SSM) with excision of the nipple and preservation of the areola skin. It is unclear whether a bilateral RRM leads to better survival compared with intensive surveillance. The oncological risk associated with the presence of remnant breast glandular tissue after SSM or nipple-sparing mastectomy has been obscure. We report the first case of RRM for a Japanese BRCA mutation carrier and provide a literature review on risk management for BRCA mutation carriers with a focus on the concepts and procedures of RRM.

"Mini-Flow-Through" Deep Inferior Epigastric Perforator Flap for Breast Reconstruction with Preservation of Both Internal Mammary and Deep Inferior Epigastric Vessels

This procedure was developed for preservation of the rectus muscle components and deep inferior epigastric vessel after deep inferior epigastric perforator (DIEP) flap harvesting. A 53-year-old woman with granuloma caused by silicone injection underwent bilateral nipple-sparing mastectomies and immediate reconstruction with "mini-flow-through" DIEP flaps. The flaps were dissected based on the single largest perforator with a short segment of the lateral branch of the deep inferior epigastric vessel that was transected as a free flap for breast reconstruction. The short segments of the donor deep inferior epigastric vessel branch are primarily end-to-end anastomosed to each other. A short T-shaped pedicle mini-flow-through DIEP flap is interposed in the incised recipient's internal mammary vessels with two arterial and four concomitant venous anastomoses. Although it requires multiple vascular anastomoses and a short pedicle for the flap setting, the mini-flow-through DIEP flap provides a large pedicle caliber, enabling safer microsurgical anastomosis and well-vascularized tissue for creating a natural breast without consuming time or compromising the rectus muscle components and vascular flow of both the deep inferior epigastric and internal mammary vessels.

Bilateral Florid Juvenile Fibroadenomas of the Breast in an Adolescent: A Rare Indication for Subcutaneous Mastectomy

BACKGROUND

Juvenile fibroadenomas are rare and constitute about 0.5% to 4% of all fibroadenomas. They present as circumscribed, often large breast masses in adolescent females and are usually managed with simple enucleation.

CASE

A 15-year-old girl presented with a 6-month history of rapidly growing breasts. On examination, she was found to have large, diffusely nodular breasts with marked asymmetry. Ultrasound and fine needle aspiration cytology results were suggestive of fibroadenomas, and the patient was planned for excision through a submammary incision.

SUMMARY AND CONCLUSION

During surgery, both the breasts were found to be studded with nodules of varying sizes with very little normal breast tissue. A bilateral subcutaneous mastectomy was performed for complete removal of the fibroadenomas. Histopathology was reported as multiple juvenile fibroadenomas. Both breasts were later reconstructed with a latissimus dorsi myocutaneous flap with implants. We present this case to highlight a rare indication for bilateral subcutaneous mastectomy for a benign condition of the breast.

Surgical Strategies in the Treatment of Gynecomastia Grade I-II: The Combination of Liposuction and Subcutaneous Mastectomy Provides Excellent Patient Outcome and Satisfaction

BACKGROUND

Gynecomastia (GM) is a benign condition with glandular tissue enlargement of the male breast. GM is classified into 4 grades of increasing severity. We describe a series of GM grade I-II, diagnosed, treated surgically and analyzed regarding feasibility, complication rate, and satisfaction.

METHODS

From 2005 to 2012, a chart review was performed for 53 patients. Preoperative examination included endocrine and urological examination and exclusion of other pathological conditions. The surgical technique consisted of liposuction through an inframammarian-fold incision and excision of the glandular tissue by a minimal periareolar approach.

RESULTS

A total number of 53 male patients with 104 breasts were available for analysis. By liposuction, a median of 300 ml (range: 10-1000 ml) was aspirated from each breast and 25.1 g (range: 3-233 g) gland tissue was resected. Surgery lasted between 25 and 164 min per patient (median: 72 min). 2 postoperative hemorrhages occurred (n = 2, 3.8%). 2 patients underwent re-operation due to cosmetic reasons (n = 2, 3.8%).

CONCLUSIONS

This analysis demonstrates that treatment of GM grade I-II can easily be performed by liposuction combined with subcutaneous resection of the glandular tissue as a minimally invasive and low-impact surgical treatment with a low rate of complications and excellent patient satisfaction. Preoperative workup is important to rule out specific diseases or malignancy causing the GM.

Therapeutic nipple-sparing mastectomy: trends based on a national cancer database

BACKGROUND

Current reports on nipple-sparing mastectomy (NSM) are limited to single-institution series. We use the National Cancer Institute's Surveillance, Epidemiology, and End Results database to report on the national experience with NSM.

METHODS

Population-level deidentified data were extracted from the Surveillance, Epidemiology, and End Results database. All female breast cancer patients treated with NSM from 2005 to 2009 were included. Case analysis was performed with respect to demographic and oncologic characteristics.

RESULTS

Four hundred forty-nine patients underwent therapeutic NSM; this number increased from 66 patients in 2005 to 133 in 2009. Patients were distributed across 16 regions, although nearly 50% were from a region of California. Tumor diameter was <2 cm in 224 patients (50%). Lymph nodes were positive in 59 patients (13%), while radiation was delivered to 74 patients (16%).

CONCLUSIONS

NSM use has been increasing over the past several years. A majority of patients have tumor size <2 cm, although the number of patients with tumor size ≥2 cm has increased over time. Further population-based studies of NSM may benefit from collection of oncologic data such as tumor-to-nipple distance and tumor location.