Safety of Incision Placement with Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction

Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.

A New Convenient Incision Model of the Nipple-Sparing Mastectomy: Lateralized Parabolic Multiplanar Incision

BACKGROUND

In this study, a lateralized parabolic multiplanar incision was defined. It was aimed to reduce necrosis in the nipple-areola complex (NAC) and, in the long run, to prevent the scar from pulling the areola laterally by maintaining healthy skin tissue between the scar and the areola and preserving the natural round appearance of the areola. Moreover, we purposed the scar not to be visible from the anterior view.

METHODS

The study included 243 patients who underwent nipple-sparing mastectomy and immediate implant-based breast reconstruction. The incision was made 4-5 cm away from the lateral border of the NAC. The incision was completed after passing the anterior axillary line by drawing a parabolic curve in superolateral axis.

RESULTS

The mean follow-up period was 24.6 months, and the mean age of the patients was 42.3 years. Full-thickness necrosis of the NAC occurred in 3.6% of breasts. In long-term follow-ups, the incision scar measured an average length of 8.6 cm. None of the patients had lateral displacement of the NAC. The NAC preserved its round appearance, except for 12 breasts that had full-thickness NAC necrosis. Ten breasts had an unnatural breast appearance.

CONCLUSION

The lateralized parabolic multiplanar incision is an ideal incision model for nipple-sparing mastectomy, as it allows for the exposure and reconstruction of all breast quadrants. We maintain areolar circulation; there are no visible scars when viewed anteriorly. Furthermore, it prevents lateral displacement of the NAC, ensuring that the natural round form of the NAC is not distorted.

LEVEL OF EVIDENCE IV

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Single stage direct -to- implant breast reconstruction following mastectomy (The use of Ultrapro® Mesh)

BACKGROUND

Immediate breast reconstruction (IBR) with direct to implant (DTI) is the preferred method of reconstruction by many surgeons and patients, however, acellular dermal matrix (ADM) and other synthetic meshes are expensive especially in low- and middle-income countries. AIM OF THE WORK: To evaluate the technique, indications, aesthetic outcomes, and short and long-term complications of DTI breast reconstruction performed with Ultrapro®, a low-cost alternative mesh to ADM and other synthetic meshes.

METHODS

Our study is a prospective cohort study that was conducted on 133 patients who experienced IBR following nipple-sparing mastectomy (NSM) or skin sparing mastectomy (SSM) using silicone implants and Ultrapro® mesh between December 2020 and December 2023. Techniques used were either sub-pectoral or pre-pectoral, evaluating aesthetic outcome, complication rate and patient satisfaction using breast Q questionnaire.

RESULTS

We included 133 patients (141 breasts) with a median age of 39 years. Mean duration of follow up: 20.364 ± 5.39 months. The sub-pectoral and the pre pectoral techniques were used for 80 breasts and 61 breasts respectively. We used the Ultrapro® mesh in all our patients. Smooth round silicone implants were used. The overall Major complications rate was 16.3%. 8 implants (5.7%) were lost within 6 months post-operatively while 2 implants were removed in the late post-operative period (after 6 months) one due to rupture and the other due to local recurrence. Capsular contracture Baker 3 and 4 was observed in 36 breasts (25%), 31 of them had post mastectomy radiotherapy treatment. 11 (7.8%) were managed by capsulotomies and re-insertion of the same implant. Radiotherapy was a significant risk factors for major complications and capsular contracture with p value of (0.01) and (0.0001) respectively.

CONCLUSION

DTI in properly selected patients offers excellent outcomes and patient satisfaction. The complication rate is low and improves with the experience of the surgeon. The Ultrapro® mesh is a safe, low-cost alternative to ADM or other synthetic meshes especially in low socioeconomic countries. Radiotherapy is a significant risk factor for major complications and capsular contractures.

Comparing Safety Profiles of Skin-Sparing and Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Analysis

BACKGROUND

Mastectomy is performed prior to or concurrently with deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the complication rates of nipple-sparing mastectomy (NSM) versus skin-sparing mastectomy (SSM) with DIEP are not well-characterized.

METHODS

This retrospective study included patients who underwent SSM or NSM with DIEP reconstruction between January 2019 and July 2022 at an academic institution. The primary outcome was 30-day postoperative complication rate. Variables were compared using Student's t-tests/Wilcoxon rank-sum and Chi-square/Fisher's exact tests.

RESULTS

Of 535 patients, 195 (36%) underwent NSM and 340 (64%) underwent SSM. The 30-day postoperative complication rates did not differ between cohorts (16.4% in NSM vs. 16.8% in SSM, p > 0.9). The NSM cohort had a higher rate of any flap necrosis (9.2% vs. 3.5%, p = 0.01) compared to the SSM cohort, though rates of total DIEP flap loss rate did not differ (4.1% vs. 1.5% respectively). Site-wide total DIEP flap loss was 2.4%. The NSM cohort had smaller preoperative sternal notch-to-nipple distances (25.0 vs. 26.5 cm, p < 0.001) and had lower rates of preoperative radiation therapy (28.2% vs. 42.9%, p < 0.002) compared to the SSM cohort. The cohorts did not differ in demographic or operative variables including reconstruction timing (delayed vs. immediate interval), readmission, and reoperation.

CONCLUSIONS

Individuals who received an NSM prior to DIEP reconstruction had more flap complications compared to the SSM cohort. Both cohorts had comparable overall 30-day postoperative complication rates and demographic variables, and rate of total DIEP flap loss was 2.4%. Patient preference can further guide surgical decision-making.

[Post-mastectomy necrotizing fasciitis and immediate prosthetic breast reconstruction: First case report]

Necrotizing fasciitis is a rapidly progressive soft tissue infection extending from the skin to the fascia, resulting in extensive necrosis. It is a very rare but serious complication, with mortality ranging from 10 to 15%. Optimal management involves early diagnosis followed by treatment combining antibiotic therapy and wide surgical removal as soon as possible. Localisation in the breast is uncommon. Although most cases are primary necrotizing fasciitis of the breast, several cases of necrotizing fasciitis have been reported in the post-operative aftermath of breast surgery. We present a case of necrotizing fasciitis of the breast following submammary mastectomy with immediate reconstruction using a pre-pectoral silicone implant, which resulted in multiple organ failure and the death of the patient despite optimal medical and surgical management. This is the first case to occur after immediate breast reconstruction.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

PURPOSE

Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk.

METHODS

A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant.

RESULTS

Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06).

CONCLUSIONS

Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

Nipple-Sparing Mastectomies in Patients over the Age of 60 Years: Factors Associated with Surgical Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) outcomes in the elderly have not been well characterized. The goal of this study was to evaluate NSM outcomes in patients over age 60.

PATIENTS AND METHODS

A single-institution retrospective cohort study was performed for NSM patients over the age of 60 from January 2004 to January 2022. Demographic, intraoperative, and postoperative variables were collected.

RESULTS

We identified 136 women who underwent a total of 200 NSMs at a mean age 65.2 years and with mean body mass index of 25. Most (56%) had invasive breast cancer, requiring neoadjuvant chemotherapy in 15%, and 17.5% had radiation prior to NSM. A total of 91% had immediate tissue expander placement. The infection rate was 19%, with 11.5% requiring expander explantation in the follow-up period. In binomial logistic regression analysis, prior radiation increased the odds of any complication by 2.9 (OR 2.93, CI 1.30-6.58, p = 0.009) and increased the odds of infection by 5.7 (OR 5.70, CI 1.95-16.66, p = 0.001), but no associations were seen for other covariates including age, comorbidities, prior chemotherapy, or presence of invasive disease. Diabetes increased the odds of wound breakdown specifically by 9.0 (OR 8.97, CI 2.01-39.92, p = 0.004). Local recurrence was 3% in mean 3.4-year follow-up.

CONCLUSIONS

Our data support NSM in patients over the age of 60 years with acceptable outcomes within the standard of care. Locoregional recurrence was within the cited range of 0-5%, and only diabetes and prior radiation were associated with reconstructive complications. NSM should thus be offered when appropriate regardless of increased age to achieve oncologic and reconstructive goals.