Nipple-Areola Complex Sensation after Nipple-sparing Mastectomy

Assessing Perioperative Complications and Cost of Nipple-Areolar Complex Neurotization in Immediate Implant-Based Breast Reconstruction Following Nipple-Sparing Mastectomy: A Matched-Paired Comparison

BACKGROUND

Reports suggest neurotization can help restore sensation in patients undergoing implant-based breast reconstruction (IBBR) following nipple-sparing mastectomy (NSM). There is a dearth of information regarding the outcomes and cost associated with neurotization of the nipple-areola complex (NAC). The objective of this study is to determine perioperative complications of performing NAC neurotization in IBBR and analyze the added cost of performing this procedure.

METHODS

A retrospective chart review was performed of patients who underwent NSM with IBBR. Breasts undergoing neurotization of the NAC were compared to breasts that did not undergo neurotization using 2:1 propensity score matching on age, reconstruction type, and BMI. Primary endpoints included 30-day complications and cost. Statistical analysis included descriptive statistics, t tests, and chi-square tests where applicable with a predetermined level of significance of P < 0.05.

RESULTS

A total of 15 patients (26 breasts) were in the neurotized cohort and matched to 30 patients (52 breasts) in the nonneurotized cohort. Mean follow-up period was 10 months and significantly lower in neurotized group (P < 0.001). Rates of major and minor complications did not vary by neurotization (P > 0.05). Cases of neurotization added a mean cost of $7839 per breast.

CONCLUSIONS

As NAC neurotization introduces increased complexity from coordination with the oncologic surgeons, use of microsurgical instruments, and additional implantable devices, it is important to compare perioperative outcomes to standard breast reconstruction. As our institution begins to offer this new technique, we have identified no increased risk of perioperative complications with NAC neurotization.

Initial Outcomes of a Novel Technique of Nipple Sparing Mastectomy Without Reconstruction

Introduction: Nipple sparing mastectomy is oncologically safe and has a good cosmetic outcome. However, nipple sparing mastectomy was conventionally performed with reconstruction. Minimal scar mastectomy (MSM) is a novel technique which could allow women, with non-ptotic breasts, who do not want reconstruction, to conserve their nipple areolar complex (NAC) and avoid the transverse scar associated with modified radical mastectomy. This is the first study on the outcomes of MSM. Methods: MSM complications and their risk factors, recurrence rates and cosmetic outcomes were assessed. As MSM is a modification of the round block technique, the mean ring distance (MRD), which is the average of the distance between the inner and outer ring circumferentially, was assessed, too. Results: A total of 28 patients (29 breasts) were analysed. There was no recurrence after a mean/median follow-up of 40.3/41 months (4-80 months). In the initial recruitment of 17 patients (18 breasts), NAC necrosis occurred in eight cases (three complete, five partial). Prediabetes (p = 0.0128) and MRD ≥1.5 cm (p = 0.0440) were statistically significant for NAC necrosis. Of the available data, 11/15 (73.3%) rated the cosmetic outcome as excellent/good, with poorer cosmetic outcome correlated with NAC necrosis (p = 0.006). Avoiding the above risk factors in the next 11 patients, NAC necrosis decreased to 1/11 (9.0%) with mild ischaemia. Cosmetic outcome was rated as excellent/good in 90.9%. Conclusions: MSM is oncologically safe and is best performed in patients with no risk factors for NAC necrosis, including prediabetes and MRD < 1.5 cm. These pilot results will refine the selection criteria of patients for MSM.

Long-Term Follow-Up of Gender-Affirming Chest Masculinization: What Have We Learned About Patient Satisfaction and Psychological Well-Being?

Background: Gender-affirming surgery has become an integral part of the gender transition process that transgender and gender-diverse individuals undergo. Although ample literature exists on the short-term outcomes of gender-affirming surgery, very little is known about the long-term implications the surgery has on the psychological well-being of the patients. The purpose was to understand the long-term impact that gender-affirming surgery has on transgender and gender-diverse individuals and gain insight on potential contributors to improved psychological well-being and satisfaction. Methods: All patients who were operated on by a single surgeon during a 20-year period were invited to the clinic for a follow-up appointment. The patients were physically examined, their scars were graded, and NAC sensation was evaluated. BUT (A and B) and BREAST-Q questionnaires were filled out by them and evaluated by the research staff. Results: Satisfaction with pre-operative information provided to the patient was associated with satisfaction with the final appearance of the chest (R = 0.717, p < 0.001), the surgical outcome (R = 0.481, p = 0.037), psychosocial well-being at follow up (R = 0.489, p = 0.034), satisfaction with the surgeon (R = 0.486, p = 0.035), satisfaction with the medical team (R = 0.62, p = 0.005) and satisfaction with the office staff (R = 0.65, p = 0.003). Conclusions: Pre-operative communication between the medical staff and the patients improves the psychological outcomes and satisfaction of the patients over the years.

Nipple-areolar complex sensory recovery based on incision placement after nipple-sparing mastectomy: a prospective nonrandomized controlled trial

INTRODUCTION

Nipple-sparing mastectomy (NSM) aims to improve patient satisfaction by preserving the nipple-areola complex (NAC) while ensuring oncologic safety. Different surgical incisions, such as inframammary fold (IMF) and periareolar/radial incisions, are used in NSM; however, their impact on NAC sensory loss remains unclear. In this study, the authors aimed to assess NAC sensation after NSM and compare the results of different incisional approaches, specifically IMF versus periareolar/radial.

METHODS

In this prospective, single-center, nonrandomized controlled trial, 105 post-NSM patients were recruited from October 2019 to November 2021 and followed up at 24-48 months postsurgery. Of these, 97 (IMF: 65; periareolar/radial: 32) were analyzed for sensory assessment. NAC sensation was measured using the pin-prick test, with scores ranging from 0 (no sensation) to 2 (sharp sensation) across five NAC areas. Sensory loss was defined as a total score below 3.

RESULTS

The median total score on the pin-prick test for NAC sensation was significantly higher in the IMF incision group than in the periareolar/radial incision group (3.77±3.11 vs. 2.47±2.51; P=0.043). The rate of NAC sensory loss was significantly lower in the IMF group than in the periareolar/radial group (36.9% vs. 62.5%; P=0.017). Multivariable analysis revealed that the incisional approach (95% CI: 0.14-0.97; P=0.044) and radiotherapy (95% CI: 0.05-0.36; P<0.01) were independent determinants of NAC sensory loss.

CONCLUSION

Our study emphasized the importance of incision placement during NSM in preserving NAC sensation and may provide a valuable perspective for clinicians and patients considering this surgical approach.

Impact of Mastectomy Flap Necrosis on Patient-Reported Quality-of-Life Measures After Nipple-Sparing Mastectomy: A Preliminary Analysis

BACKGROUND

Mastectomy skin flap necrosis (SFN) is common following nipple-sparing mastectomy (NSM), but studies on its quality-of-life (QOL) impact are limited. We examined patient-reported QOL and satisfaction after NSM with/without SFN utilizing the BREAST-Q patient-reported outcome measure (PROM) survey.

PATIENTS AND METHODS

Patients undergoing NSM between April 2018 and July 2021 at our institution were examined; the BREAST-Q PROM was administered preoperatively, and at 6 months and 1 year postoperatively. SFN extent/severity was documented at 2-3 weeks postoperatively; QOL and satisfaction domains were compared between patients with/without SFN.

RESULTS

A total of 573 NSMs in 333 patients were included, and 135 breasts in 82 patients developed SFN (24% superficial, 56% partial thickness, 16% full thickness). Patients with SFN reported significantly lower scores in the satisfaction with breasts (p = 0.032) and psychosocial QOL domains (p = 0.009) at 6 months versus those without SFN, with scores returning to baseline at 1 year in both domains. In the "physical well-being-of-the-chest" domain, there was an overall decline in scores among all patients; however, there were no significant differences at any time point between patients with or without SFN. Sexual well-being scores declined for patients with SFN compared with those without at 6 months and also at 1 year, but this did not reach significance (p = 0.13, p = 0.2, respectively).

CONCLUSIONS

Patients undergoing NSM who developed SFN reported significantly lower satisfaction and psychosocial well-being scores at 6 months, which returned to baseline by 1 year. Physical well-being of the chest significantly declines after NSM regardless of SFN. Future studies with larger sample sizes and longer follow-up are needed to determine SFN's impact on long-term QOL.

Patient Satisfaction, Esthetic Outcome, and Quality of Life in Oncoplastic and Reconstructive Breast Surgery: A Single Center Experience

Background

Oncoplastic surgery has become an important part of the surgical repertoire to offer both oncologically safe and aesthetically pleasing results in patients with breast cancer. Data comparing oncoplastic and reconstructive breast surgeries are limited. This study aimed to assess patient-reported outcomes (PRO) in our cohort of oncoplastic and reconstructively operated patients.

Methods

Patients who underwent oncoplastic surgery, including immediate reconstruction by a single surgeon, between 2010 and 2018 were contacted to participate in this study. In total, 157 patients fulfilled the inclusion criteria. 54 patient data sets were used for statistical evaluation. Body Image Scale (BIS) and BreastQ questionnaires were used to measure subjective PRO scores, and pictures were taken to objectively measure symmetry using the Breast Analyzing Tool (BAT). Patients were divided into three groups according to the Tübingen classification (group 1: Tübingen 3-4 (n = 16), group 2: Tübingen 5 (n = 26), group 3: Breast Reconstruction/Tübingen 6 (n = 12]).

Results

The mean age was 53.5 for group 1, 51.4 for group 2 and 46.8 for group 3. The mean follow-up was 62.9 ± 35.82 months. BIS was significantly better in group 3 (3.92 ± 1.73) than in group 1 and 2 (7.69 ± 4.48 and 4.81 ± 3.41, p = 0.016). Symmetry measured using BAT showed only a trend favoring reconstruction (p = 0.12). The BreastQ item "Sexual well-being" was significantly better in oncoplastic breast reduction surgery (p = 0.036).

Conclusion

BIS was better after reconstructive breast surgery than after oncoplastic surgery. Reconstructive breast surgery in experienced breast care units offers high patient satisfaction and a high quality of life.

Careful Where You Cut: Strategies for Successful Nerve-preserving Mastectomy

Breast neurotization represents an evolving technique that is not widely practiced in most centers specializing in breast cancer treatment. Recognizing the limited educational resources available for breast and plastic surgeons concerning mastectomy techniques that emphasize nerve preservation, our study sought to bridge this gap. Specifically, we aimed to provide a comprehensive exploration of the surgical applied anatomy of breast sensory innervation and a detailed, step-by-step guide for incorporating nerve-sparing mastectomy and breast neurotization into clinical practice. The significance of this work lies in its potential to enhance the understanding and implementation of nerve-preserving techniques in mastectomy procedures, contributing to improved patient outcomes and quality of life post surgery. We hope that by familiarizing breast and reconstructive surgeons with this procedure, we can gain momentum in our research efforts and ultimately enhance the care provided to mastectomy patients.

Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis

Purpose

As breast-conserving procedures become increasingly safe and viable options for surgical management of breast cancer, efforts have focused on assessing and optimizing patient-reported outcome measures (PROMs), such as nipple sensation. This study aims to evaluate the current understanding of nipple-areolar complex (NAC) sensation outcomes in breast cancer patients undergoing breast cancer surgeries, namely, nipple-sparing mastectomies (NSM), skin-sparing mastectomies (SSM), and lumpectomies.

Methods

Articles including terms related to "nipple," "mastectomy," "sensation," and "patient-reported outcome" were queried from three databases according to PRISMA guidelines. Study characteristics, patient demographics, and surgical details were recorded. Outcomes of interest included objective nipple sensitivity testing and PROMs.

Results

Of 888 manuscripts identified, 28 articles met the inclusion criteria. Twelve studies (n = 578 patients) used objective measures to evaluate sensitivity, such as monofilament testing. Sixteen studies (n = 1785 patients) assessed PROMs through validated or investigator-generated surveys. Three of the included studies reported NAC sensitivity in patients who received NSM with neurotization (n = 203 patients) through a variety of techniques that used various grafts to coapt a lateral intercostal nerve to the NAC nerve stumps. Results of investigator surveys showed that of 1565 patients without neurotization, nipple sensation was maintained in 29.0% (n = 453) of patients. Of 138 NSM patients without NAC neurotization, SWM testing showed an average loss of protective sensation in the nipple (average SWM score: 4.7) compared to normal or diminished sensation to light touch in nonoperated controls (average SWM score: 2.9, n = 195). Of patients who underwent NSM with neurotization, one study (n = 78) reported maintenance of NAC sensation in 100% of patients, while another study (n = 7) reported average diminished protective sensation in the nipple (average SWM score: 3.9).

Conclusion

Our study has shown that objective and patient-reported results of nipple sensitivity support nipple-sparing techniques as a viable option for preserving NAC sensation, although patients can expect a decrease in sensation overall. Neurotization of the NAC during NSM shows promising results of improved postoperative nipple sensitivity, though additional studies are warranted to confirm this finding. Variations between study methodologies highlight the lack of standardization in sensory testing techniques when evaluating NAC sensation.

The altering in sensory sensitivity: a current issue of female breast surgery

Breast surgery is an important treatment for women with malignant breast diseases. In addition to breast appearance, the integrity of breast function is increasing in patients with breast diseases. As the basis of breast physiological function, breast skin sensitivity is important to the quality of life of patients after surgery. Breast skin sensitivity gives the patient a "real" breast feeling. The sensory recovery after breast surgery has also become one of the important goals of breast surgery. In this review, we aim to discuss the research progress on recovery of breast skin sensitivity after different treatment modalities for breast disease.

The Assessment of Nipple Areola Complex Sensation with Semmes-Weinstein Monofilaments-Normative Values and Its Covariates

Objective: To establish normative data for nipple-areola complex (NAC) sensibility examined with Semmes-Weinstein monofilament test (SWMT) and two-point discrimination (TPD) in women with varying breast sizes, including women with gigantomastia. We also aimed to identify clinical variables influencing NAC sensation. Methods: A total of 320 breasts in 160 Caucasian women (mean age 33.6 years, SD 11 years) were examined (including 50 hypertrophic breasts). NACs sensation was examined using Semmes-Weinstein monofilaments (SWM) and the Weber Two-Point Discrimination Test. Results: The nipple appeared to be the most sensitive part of NAC. In normal-sized breasts, sensation thresholds (SWM) correlated with: age, BMI, history of births, breast size and ptosis (for all locations), breastfeeding history (for nipple and upper areola) and areola diameter (for all locations apart from the nipple). Regression analysis showed that age, cup size and suprasternal notch-to-nipple distance are risk factors for diminished NAC sensation. Sensation thresholds in all NAC locations of hypertrophic breasts were significantly higher compared to normal-sized breasts, while TPD tests did not differ between the groups. Conclusions: We provided normative values of NAC sensation (tactile threshold and TPD) for different NAC areas. Our investigation indicated that SWM are useful diagnostic tools when the following factors are considered while examining NAC sensation: location (nipple vs. areola), age, breast size, suprasternal notch-to-nipple distance, history of births and breastfeeding. Hypertrophic breasts presented significantly higher sensation thresholds for all NAC locations. The report may serve as a reference data for further investigations regarding NAC sensation after different breast surgeries.

Prospective pilot study protocol evaluating the safety and feasibility of robot-assisted nipple-sparing mastectomy (RNSM)

INTRODUCTION

Nipple-sparing mastectomy (NSM) can be performed for the treatment of breast cancer and risk reduction, but total mammary glandular excision in NSM can be technically challenging. Minimally invasive robot-assisted NSM (RNSM) has the potential to improve the ergonomic challenges of open NSM. Recent studies in RNSM demonstrate the feasibility and safety of the procedure, but this technique is still novel in the USA.

METHODS AND ANALYSIS

This is a single-arm prospective pilot study to determine the safety, efficacy and potential risks of RNSM. Up to 12 RNSM will be performed to assess the safety and feasibility of the procedure. Routine follow-up visits and study assessments will occur at 14 days, 30 days, 6 weeks, 6 months and 12 months. The primary outcome is to assess the feasibility of removing the breast gland en bloc using the RNSM technique. To assess safety, postoperative complication information will be collected. Secondary outcomes include defining benefits and challenges of RNSM for both surgeons and patients using surveys, as well as defining the breast and nipple-areolar complex sensation recovery following RNSM. Mainly, descriptive analysis will be used to report the findings.

ETHICS AND DISSEMINATION

The RNSM protocol was reviewed and approved by the US Food and Drug Administration using the Investigational Device Exemption mechanism (reference number G200096). In addition, the protocol was registered with ClinicalTrials.gov (NCT04537312) and approved by The Ohio State University Institutional Review Board, reference number 2020C0094 (18 August 2020). The results of this study will be distributed through peer-reviewed journals and presented at surgical conferences.

TRIAL REGISTRATION NUMBER

NCT04537312.

Breast-Specific Sensuality and Appearance Satisfaction: Comparison of Breast-Conserving Surgery and Nipple-Sparing Mastectomy

BACKGROUND

We demonstrated previously that lumpectomy (L) patients reported higher appearance satisfaction, appreciation of a pleasurable breast caress, and persistence of the breast during intimacy than mastectomy with reconstruction, which we used to describe breast-specific sensuality. Our current objective was to compare breast-specific sensuality between L and nipple-sparing mastectomy (NSM).

DESIGN

An anonymous, cross-sectional survey was distributed to breast cancer survivors between 2014 and 2016. Eligible patients underwent operation between 2000 and 2014, were adults older than 18 years, English-speaking, and at least one year into the post-operative period. Demographic characteristics, treatment details, Female Sexual Function Index metrics, and investigator-generated questions about appearance satisfaction and breast-specific sensuality were collected.

RESULTS

Of the 600 women who participated, 585 surveys were eligible. Surgical modality was reported as L by 406 (69.4%), mastectomy alone by 50 (8.5%), and mastectomy with reconstruction by 129 (22.1%). Nipple-preservation data were available for 47 of 129 mastectomy with reconstruction patients (36.4%), with 21 NSM and 26 non-nipple-sparing mastectomy patients. Favorable postoperative appearance satisfaction was reported by 76.2% of L and 71.4% of NSM (p = 0.039). Lumpectomy patients reported feeling more comfortable being seen undressed than NSM patients (82.4% vs 71.4%; p = 0.0003). The chest remained a part of intimacy for 65.4% of L patients vs 42.9% of NSM patients (p = 0.0009). A pleasurable breast caress was reported more frequently by L patients than NSM patients (66.2% vs 20%; p ≤ 0.0001). The breast caress was unpleasant for 40% of NSM patients, nearly 4-fold higher than L patients (11.3%; p < 0.0001).

CONCLUSIONS

NSM patients were significantly less satisfied with appearance, less comfortable being seen undressed, had decreased persistence of breast intimacy, and experienced a less pleasurable breast caress than L patients. Counseling patients about these findings will empower informed decision making, optimize expectations, and can enhance postoperative satisfaction.

Immediate Targeted Nipple-Areolar Complex Reinnervation: Improving Outcomes in Gender-affirming Mastectomy

Supplemental Digital Content is available in the text.

Female-to-male mastectomy often renders the chest skin and nipple–areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves and using them to reinnervate the NAC after mastectomy.

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.

Nerve Preservation and Allografting for Sensory Innervation Following Immediate Implant Breast Reconstruction

While newer breast reconstruction approaches utilizing nipple-sparing mastectomy (NSM) techniques and immediate reconstruction can provide excellent aesthetic outcomes, absent postoperative sensation remains a major limitation. Here, we present a novel technique for implant reconstruction combining the latest advances in breast oncologic, reconstructive, and peripheral nerve surgery to improve sensory outcomes. Sixteen women (31 breasts) underwent NSM and prepectoral, direct-to-implant reconstruction. During NSM, careful dissection was performed along the lateral aspect of the breast to preserve any visible intercostal nerves. When nerves could be preserved without compromising oncologic safety, they were left intact within the subcutaneous tissue of the lateral mastectomy skin flap. Nipple/areolar complex (NAC) neurotization was also performed utilizing allograft coapted from transected T₄ or T₅ lateral intercostal nerves to subareolar nerves identified at the completion of the mastectomy. Of the 12 women (23 breasts) with at least 3 months' follow-up, NAC 2-point discrimination was preserved in 20 breasts (87%), was worse in 2 breasts (9%), and had actually improved in 1 breast (4%). All patients had intact sensation to light touch throughout the majority of, if not their entire, reconstructed breasts. None of the women developed dysesthesias or neuromas. Nerve grafting in conjunction with careful nerve preservation at the time of NSM and implant-based breast reconstruction is safe and effective with a 90% rate of preserved sensation. With longer follow-up, continued return of sensation or possibly improved sensation from baseline can be reasonably anticipated.