Nipple-areolar complex (NAC) or skin flap ischemia necrosis post nipple-sparing mastectomy (NSM)-analysis of clinicopathologic factors and breast magnetic resonance imaging (MRI) features

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.

Assessing aesthetic outcomes of different incision types for nipple-sparing mastectomy followed by radiation therapy in prepectoral direct-to-implant breast reconstruction: a retrospective study

BACKGROUND

This study analyzes the aesthetic outcomes associated with inframammary fold (IMF) incisions compared to radial incisions, with or without a periareolar component (referred to as periareolar/radial, PR), considering nipple-sparing mastectomy (NSM) followed by prepectoral direct-to-implant (DTI) reconstruction and subsequent post-mastectomy radiotherapy (PMRT). We assessed changes in breast and nipple symmetry, nipple-to-IMF distance, and nipple Y-axis coefficients to understand how different incisions influence post-radiation aesthetic outcomes.

METHODS

Forty patients who underwent NSM and prepectoral DTI reconstruction followed by PMRT between September 2019 and December 2022 in a single institution were included. Patients were divided into PR incision (n = 9) and IMF incision (n = 31) groups, with the latter further separated into IMF 1 group (surgeries from 2019 to 2021, n = 13) and IMF 2 group (surgeries in 2022, n = 18). Pre- and postoperative (6-18 months after surgery) analyses of body measurements and medical photographs were conducted using the Seoul Breast Esthetic Scoring Tool (S-BEST) software, developed by same institution, to calculate breast symmetry scores, nipple-to-IMF distance, and nipple Y-axis coefficients. Statistical analyses assessed differences between groups.

RESULTS

All groups showed decreased breast symmetry scores postoperatively (PR group: -1.111, IMF 1 group: -0.539, IMF 2 group: -0.389) and increased nipple-to-IMF distance (PR group: 0-0.2 cm, IMF 1 group: 0.2-0.5 cm, IMF 2 group: 0.3-0.4 cm). The changes in nipple y-axis coefficients were minimal across all groups. And the PR group received a lower average radiation dose (47.64 ± 5.2 Gy) than IMF 1 group (54.45 ± 5.28 Gy) and IMF 2 group (54.07 ± 4.79 Gy). Statistical analysis indicated no significant differences across the groups (p > 0.05, Kruskal-Wallis test).

CONCLUSIONS

While IMF and PR incisions yielded similar aesthetic outcomes post-radiation, IMF incisions showed trends toward better symmetry, especially at higher radiation doses. These findings support the IMF incision as a favorable choice in NSM with DTI reconstruction followed by PMRT, though patient anatomy and preferences remain critical for surgical planning.

Long-Term Follow-Up of Surgical Outcomes and Oncological Results of Nipple-Sparing Mastectomy with Immediate Reconstruction Through a Single Axillary Incision with Different Approach Methods

BACKGROUND

We investigated the perioperative outcome and oncologic safety of performing nipple-sparing mastectomy (NSM) through a single axillary incision (NSM-SAI) compared with performing NSM through a conventional incision (NSM-C).

METHODS

We retrospectively reviewed 725 patients who underwent NSM for breast cancer between January 2010 and December 2023; 333 patients who underwent NSM with immediate reconstruction (IR) were enrolled. Surgical outcomes and oncologic outcomes of NSM-C (n = 184), NSM performed through SAI with a freehand approach (NSM-SAI-F; n = 92), and with an endoscopic approach (NSM-SAI-E; n = 57) were demonstrated. The risk factors for resection margins, nipple-areolar complex (NAC), and skin flap necrosis were evaluated separately for NSM-C and NSM-SAI.

RESULTS

NAC and skin flap necrosis occurrence rates among the NSM-C, NSM-SAI-F, and NSM-SAI-E groups were similar (insignificant), regardless of autologous or prosthesis reconstruction. The tumor-to-nipple distance among patients who underwent NSM-C was an independent risk factor for NAC necrosis in the NSM-C group (odds ratio [OR] 6.02, p = 0.007); being overweight and tumor location in the lower breast were risk factors for skin necrosis in the NSM-C group (OR 3.36, p = 0.041; and OR 4.32, p = 0.011, respectively). These risk factors were not associated with the NSM-SAI group. The three groups had comparable positive resection margins, local recurrence-free survival, and distant metastasis-free survival rates (p = 0.857, 0.543, and 0.975, respectively).

CONCLUSIONS

NSM-SAI combined with IR by the freehand or endoscopic approaches can provide good aesthetic outcomes and oncologic safety for well-selected patients with breast cancer. The risk factors for NAC and skin flap necrosis differ between the NSM-SAI and NSM-C groups.

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.

Safety and aesthetic outcomes of double purse-string suture nipple reconstruction in early breast cancer patients undergoing nipple resection and endoscopic skin-sparing mastectomy with breast reconstruction

Background

The current surgical methods for managing incisions after nipple excision in breast reconstruction patients are limited. However, double purse-string suture (DPS) shows promise in the treatment of nipple excision. This study aimed to investigate the safety and aesthetic outcomes of DPS nipple reconstruction in early breast cancer patients who underwent endoscopic skin-sparing mastectomy (E-SSM) and breast reconstruction.

Methods

We retrospectively analyzed the clinical data of 87 early breast cancer patients with nipple excision who underwent E-SSM with breast reconstruction. According to the suture methods of nipple incision, all patients were divided into the spindle suture (SS) group, single purse-string suture (SPS) group, and DPS group, with SS and SPS groups combined as the traditional suture (TS) group. Then, we compared the groups' differences in aesthetic outcomes, surgical safety, and oncological safety.

Results

A total of 87 patients with 88 breasts were enrolled in this study (SS n=17, SPS n=21, DPS n=50). Patients in the DPS group had significantly better nipple reconstruction satisfaction, Harris scale and any complications incidence than the TS group (all p <0.05). For nipple reconstruction satisfaction and any complication, the adjusted OR (95%CI) of the DPS group were 6.314(1.095-36.415) (p=0.039) and 0.124(0.018-0.863) (p=0.035) compared with the SS group. One patient in the SS group had vertebral metastases, and no recurrence, metastasis, or death has been observed in the other two groups during the follow-up period.

Conclusions

DPS is an effective and safe nipple reconstruction procedure for patients undergoing E-SSM with breast reconstruction, delivering excellent aesthetic outcomes.

Pilot robotic mastectomy in Singapore (PRoMiSing I) study: first safety and feasibility prospective cohort trial in South East Asia

BACKGROUND

Robotic mastectomy has been performed worldwide since 2015. The advantages of the robotic approach in nipple-sparing mastectomy have been proven with better visualization and preservation of blood supply to the nipple-areolar complex, with a lower incidence of necrosis. It also allows smaller incisions for both mastectomy and immediate breast reconstruction. To date, no centers in Singapore and Southeast Asia offer robotic mastectomy. We believe that robotic mastectomy is a feasible and safe technique that our population can utilize.

OBJECTIVES

This study aimed to ascertain the surgical outcomes and perform a learning curve analysis in patients undergoing robotic mastectomy in a multi-ethnic South East Asian population.

METHODS

A single-arm prospective pilot study of eligible patients aged 21-70 years old with early breast cancer or high-risk patients indicated for risk-reducing mastectomy who were eligible and consented to robotic mastectomy were enrolled in this trial from December 22, 2022 to December 15, 2023.

RESULTS

A total of 29 consecutive robotic mastectomies were performed. The mean total operative time was 95±10.2 min. The average blood loss was 5.7±1.9 ml, and the average length of stay was 1.05 days. The mean mastectomy specimen weight was 251 g, and there was no conversion to conventional mastectomy in any case. Furthermore, there were no 30-day morbidity or complications in terms of wound infection requiring intervention, flap, and nipple-areolar complex necrosis, and postoperative hematoma/bleeding requiring intervention.

CONCLUSION

This study contributes to the current evidence that robotic mastectomy is a safe and feasible option and could prove to be a great alternative to conventional mastectomy. Further prospective trials examining the long-term oncological outcomes of robotic mastectomy will be performed to establish the oncologic safety of this technique in breast cancer treatment.

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.

A novel technique of reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction: medium-term oncological safety outcomes and feasibility of 24-h discharge for breast cancer patients

BACKGROUND

Due to the short operation time and no need for special instruments, reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) has been rapidly becoming popular in the last three years. However, there has yet to be an evaluation of its oncologic safety or the feasibility of discharging patients within 24 h.

MATERIALS AND METHODS

In this single-centre retrospective cohort study, individuals diagnosed with stage 0-III breast cancer between May 2020 and April 2022 who underwent traditional open mastectomy or R-E-NSM with DIBR were included. Follow-up started on the date of surgery and ended in December 2023. Data, including demographics, tumour characteristics, medium-term oncological outcomes, and postoperative complications, were collected and analyzed. Propensity score matching (PSM) was performed to minimize selection bias.

RESULTS

This study included 1679 patients [median (IQR) age, 50 [44-57) years]. Of these, 344 patients underwent R-E-NSM with DIBR (RE-R group), and 1335 patients underwent traditional open mastectomy (TOM group). The median [IQR] follow-up time was 30 [24-36] months [29 (23-33) months in the RE-R group and 30([24-36) months in the TOM group]. Regarding before or after PSM, the P value of local recurrence-free survival (LRFS, 0.910 and 0.450), regional recurrence-free survival (RRFS, 0.780 and 0.620), distant metastasis-free survival (DMFS, 0.061 and 0.130), overall survival (OS, 0.260 and 0.620), disease-free survival (DFS, 0.120 and 0.330) were not significantly different between the RE-R group and the TOM group. The 3y-LRFS and 3y-DFS rates were 99.0% and 97.1% for the RE-R group and 99.5% and 95.3% for the TOM group, respectively. The rates of any complications and major complications were not significantly different between the RE-R patients who were discharged within 24 h and the RE-R patients who were not discharged within 24 h ( P =0.290, P =0.665, respectively) or the TOM patients who were discharged within 24 h ( P  =0.133, P =0.136, respectively).

CONCLUSIONS

R-E-NSM with DIBR is an innovative oncologic surgical procedure that not only improves cosmetic outcomes but also ensures reliable oncologic safety and fewer complications, enabling patients to be safely discharged within 24 h. A long-term prospective multicenter assessment will be supporting.

Is minimal-accessed (endoscopic- or robotic-assisted) nipple-sparing mastectomy contraindicated for large breasts?

BACKGROUND

In the developmental stage of minimal-accessed nipple-sparing mastectomy (MA-NSM), selecting patients with small to medium-sized breasts was common for better cosmetic outcomes and oncological safety. However, the suitability of MA-NSM for large, ptotic breasts remained uncertain. This retrospective study aim to assess MA-NSM outcomes in patients with large breasts.

MATERIALS AND METHODS

This retrospective study included patients receiving conventional NSM (C-NSM) and MA-NSM from January 2011 to September 2022, at a single institution. We analyzed perioperative parameters and clinical outcomes based on breast specimen size, classified as small (≤300 g), medium (>300-450 g), large (>450-600 g), and very large (>600 g).

RESULTS

A total of 728 patients was enrolled. C-NSM was performed in 51% (371/728) of cases, while MA-NSM was done in 49% (357/728). The overall complication rate of MA-NSM was comparable to C-NSM (p = 0.573), but severe complications (Clavien-Dindo, CD III) was significantly reported more following C-NSM, regardless of breast size. During a median follow-up of 52 months, no significant difference in oncological outcomes was observed. Comparing MA-NSM and C-NSM outcomes in large-very large breasts (>450 g), MA-NSM demonstrated significantly less blood loss (p = 0.036) and lower incidence of severe complications (CD ≥ III) compared to C-NSM (p = 0.002).

CONCLUSION

MA-NSM is feasible for large breasts and offers benefits by reducing blood loss and decreasing the incidence of severe complications (CD ≥ III) in this patient group.

Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery

Background

Our center proposes a new technique that effectively provides space to broaden the surgical field of view and overcomes the limitations of endoscopy-assisted nipple-sparing mastectomy (E-NSM) by changing the dissection sequence and combining it with air inflation. The purpose of this study was to compare the clinical outcomes of the new technique designated "reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with subpectoral breast reconstruction (SBR)" and the conventional E-NSM (C-E-NSM) with SBR.

Method

All patients undergoing E-NSM with SBR at our breast center between April 2017 and December 2022 were included in this study. The cohort was divided into the C-E-NSM group and the R-E-NSM group. The operation time, anesthesia time, medical cost, complications, cosmetic outcomes, and oncological safety were compared.

Results

Twenty-six and seventy-nine consecutive patients were included in the C-E-NSM and R-E-NSM groups, with average ages of 36.9 ± 7.0 years and 39.7 ± 8.4 years (P=0.128). Patients in the R-E-NSM group had significantly shorter operation time (204.6 ± 59.2 vs. 318.9 ± 75.5 minutes, p<0.001) and anesthesia time (279.4 ± 83.9 vs. 408.9 ± 87.4 minutes, p<0.001) and decreased medical costs [5063.4 (4439.6-6532.3) vs. 6404.2 (5152.5-7981.5), USD, p=0.001] and increase SCAR-Q scores (77.2 ± 17.1 vs. 68.8 ± 8.7, P=0.002) compared to the C-E-NSM group. Although trends increased in both the excellent rate of Ueda scores (53.8% vs. 42.3%, P = 0.144), excellent rate of Harris scores (44.0% vs. 63.1%, P=0.102), and decreased surgical complications (7.6% vs. 19.2%, P = 0.135) were observed in the R-E-NSM group, the differences were not significant. There were no significant differences in oncological outcomes between the two groups.

Conclusion

R-E-NSM improves cosmetic outcomes and efficiency of C-E-NSM, reduces medical costs, and has a trend of lower surgical complications while maintaining the safety of oncology. It is a safe and feasible option for oncological procedures that deserves to be promoted and widely adopted in practice.

Factors associated with alteration of nipple or skin sensation and impact of duration of time following nipple-sparing mastectomy (NSM): an analysis of 460 cases with comparison of conventional versus endoscopic- or robotic-assisted NSM

BACKGROUND

The current study aims to evaluate the nipple and skin sensation following nipple-sparing mastectomy (NSM) and identify patient-, surgical-, or treatment-related factors affecting nipple or skin sensation in this cohort.

METHODS

Patients who received NSM with postoperative nipple and skin sensation test evaluation at a single institution over the past 10 years were retrospectively retrieved from a prospectively collected breast cancer surgery database.

RESULTS

A total of 460 NSM procedures were included in this current study, with the mean age of 48.3 ± 9.1. Three-hundred eighty-three (83.3%) patients had breast reconstructions. One-hundred seventy-four (37.8%) received conventional NSM (C-NSM), 195 (42.4%) endoscopic-assisted NSM (E-NSM), and 91 (19.8%) robotic-assisted NSM (R-NSM) procedures. For nipple sensation assessment, 15 (3.3%) were grade 0, 83 (18.2%) grade I, 229 (49.7%) grade II, and 133 (28.9%) grade III (normal sensation), respectively, with mean grade score of 2.1 ± 0.7. The preserved (grade III) nipple sensation rate was 36.2% (63/174) in the C-NSM group, 26.7% (52/195) in the E-NSM group, and 19.7% (18/91) in the R-NSM group (P = 0.06). The "time since surgery to last evaluation" was significantly longer in the C-NSM group (45.6 ± 34 months) or E-NSM group (44.7 ± 35.8 months) as compared to R-NSM group (31.8 ± 16 months, P < 0.01). In multivariate analysis, peri-areolar incision showed higher grade of nipple sensation (OR: 2.1, P = 0.02) compared to upper outer quadrant incision, and longer follow-up time post-NSM showed significant improvement of nipple or skin sensation (> 60 months vs. ≦ 12 months: nipple odds ratio (OR) = 5.75, P < 0.01; skin, OR = 1.97, P < 0.05).

CONCLUSION

Our current analysis showed some factors to be related to postoperative nipple or skin sensation, and longer "time after surgery" was associated with significant improvement of nipple and skin sensation in patients who received NSM, regardless of the surgical approaches.

SYNOPSIS

Our current analysis showed a significant portion of patients with decrease or loss of nipple or skin sensation after nipple-sparing mastectomy (NSM). Several factors associated with preserved nipple or skin sensation were identified, including age, surgical methods, surgical wound location, and association of time from surgery showing that improvement of partial nipple or skin sensation was evident after a longer follow-up.