Skin-sparing mastectomy

Autologous Breast Reconstruction with Free Nipple–Areola Graft after Circumareolar (Skin Reducing) Mastectomy

Introduction of skin-sparing mastectomy (SSM) led to a paradigm shift in breast reconstruction. Primary reconstructions have become the therapy of choice. At the same time, immediate autologous reconstructions are oncologically safe and aesthetically pleasing. Our preferred SSM incision is the circumareolar with removal of nipple and areola (NAC). Adjustment of the skin envelope is well accomplished in mild-to-moderate ptotic breasts. We describe our technique consisting of circumareolar incision in SSM, keeping the NAC as a free graft, and immediate autologous reconstruction and immediate free NAC grafting on the flap. Aesthetic indications are slight asymmetries, ptotic breasts, large breasts where the reconstructed breast will be smaller than the original breast and where a Wise pattern is not indicated. Oncologic indications are risk-reducing mastectomies and tumors close to the NAC where resection would compromise the vitality of the NAC. We evaluated the healing of the NAC and the NAC position with regard to the breast shape. From 2019–2022, 296 autologous flaps were used for breast reconstruction. In 36 flaps, this technique was applied. Eighteen flaps were bilateral (nine patients). In total, we performed 15 inner thigh flaps and 21 DIEP flaps. No flap or NAC loss occurred. There was no wound healing complication at the breast, and no adjuvant chemotherapy or radiation therapy needed to be postponed. The advantages of this technique are (1) scar reduction with only one periareolar scar on the breast, which is also well concealed; (2) oncological safety in relation to the nipple and optimal visibility of the mastectomy cavity, which allows a meticulous mastectomy, especially important in risk-reducing mastectomies; (3) generally, fewer wound healing problems, especially fewer than with Wise pattern incision; (4) primary adjustment of the skin envelope and positioning of the NAC are easier to perform than in a secondary procedure; and (5) that the NAC is spared, and no secondary reconstruction is necessary. Disadvantages are that (1) the NAC must heal as a free graft and (2) that the sensitivity of the NAC is lower than in pedicled NAC transposition.

Passot-Type Immediate Breast Reconstruction Obviates the Use of Aceullular Dermal Matrix in Grades 2 and 3 Ptosis

PURPOSE

Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM.

METHODS

All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided.

RESULTS

Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case).

CONCLUSIONS

Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.

Immediate Breast Reconstruction Does Not Have a Clinically Significant Impact on Adjuvant Treatment Delay and Subsequent Survival Outcomes

Purpose

The use of immediate breast reconstruction (IBR) has been debated because it may be a causative factor in adjuvant treatment delay and may subsequently increase the probability of recurrence. We investigated whether IBR was related to adjuvant treatment delay and survival outcomes.

Methods

We retrospectively analyzed the duration from operation to adjuvant treatment administration and survival outcomes according to IBR status among patients with breast cancer who underwent mastectomy followed by adjuvant chemotherapy from January 2005 to December 2014. Propensity score matching was performed to balance the clinicopathologic baseline characteristics between patients who did and did not undergo IBR.

Results

Of 646 patients, 107 (16.6%) underwent IBR, and the median follow-up was 72 months. The median duration from surgery to adjuvant chemotherapy was significantly longer in patients who underwent IBR than in those who did not (14 vs. 12 days, respectively, p = 0.008). Based on propensity score matching, patients who underwent IBR received adjuvant therapy 3 days later than those who did not (14 vs. 11 days, respectively, p = 0.044). The duration from surgery to post-mastectomy radiation therapy (PMRT) did not significantly differ between the 2 groups. Local recurrence-free survival, regional recurrence-free survival, systemic recurrence-free survival, and overall survival were also not significantly different between the 2 groups (p = 0.427, p = 0.445, p = 0.269, and p = 0.250, respectively). In the case-matched cohort, survival outcomes did not change.

Conclusion

IBR was associated with a modest increase in the duration from surgery to chemotherapy that was statistically but not clinically significant. Moreover, IBR had no influence on PMRT delay or survival outcomes, suggesting that it is an acceptable option for patients with non-metastatic breast cancer undergoing mastectomy.

Skin-reducing oncoplasty: A new concept and classification in breast cancer surgery

BACKGROUND AND OBJECTIVES

Breast-conserving surgery and skin-sparing mastectomy are nowadays widely accepted as the standard of care in selected patients with early breast cancer. After an accurate review of the literature, it appeared that no ordered list of the numerous techniques described for conservative breast surgery has been established so far. The aim of this study was to develop a simple classification of the different skin incision patterns that may be used in breast surgery.

METHODS

A systematic review of the English literature was conducted using the PubMed database to identify all the articles reporting breast-conserving surgery and skin-sparring mastectomy techniques up to the 31st of December 2016.

RESULTS

Among the 1426 titles identified, 230 were selected for review. Based on the reviewed papers, the skin-reducing oncoplasty incision pattern (SROIP) classification was elaborated.

CONCLUSIONS

Breast cancer surgery should nowadays optimise aesthetic outcomes by improving the final breast shape, volume and scar location. This may be achieved using different procedures that we grouped together under the term skin-reducing oncoplasty (SRO). Depending on the breast cancer location, the SROIP classification helps in the choice of the best technique to be used.

Cannula-Assisted Flap Elevation (CAFE): a novel technique for developing flaps during skin-sparing mastectomies

BACKGROUND

One of the most challenging procedures in breast surgery is the skin-sparing mastectomy (SSM). Various techniques and incisions have evolved that characterize this procedure; however, what is common in all of them is the smaller the incision, the more difficult it is to develop the skin flaps.

METHODS

A procedure was developed that incorporates the use of liposuction cannulas (without suction) to create the skin flaps. The technique and results are described in this manuscript.

RESULTS

From October of 2012 to April 2014, 289 mastectomies (171 patients) were performed using the CAFE procedure on women of all shapes and sizes. Postoperatively, no problems were experienced with flap viability using this technique. The main difference in side effects between the CAFE technique and other standard techniques for developing flaps in SSMs was more bruising than normal, but this resolved rapidly. The results for use of this technique were consistently impressive. The learning curve for this procedure is very short, especially for those who perform SSMs using sharp technique (scissors). Residents and fellows became proficient with the CAFE technique in a relatively short amount of time. Plastic surgeons were pleased with the cosmetic outcomes of their reconstructions that follow this type of mastectomy. Patients were extremely satisfied with their reconstructions as well.

CONCLUSIONS

Incorporating the use of liposuction cannulas (without suction) makes the creation of flaps for SSM a relatively simple and rapid method. It is especially useful to assist in developing skin flaps with even the smallest of skin incisions.

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction

PURPOSE

Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM.

METHODS

The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision.

RESULTS

Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple-areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions.

CONCLUSION

The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.

Determination of the accuracy of juxtacapsular dissection of the breast. What is left behind?

BACKGROUND

Resectional breast surgery has become less extensive. Dissection on plane of the superficial fascia covering the breast (juxtacapsular) is used during various procedures for retention of the appearance of the breast. The accuracy of this method and its ability to remove all glandular breast tissue has never been tested.

METHODS

Twenty patients with breast cancer were studied prospectively. Juxtacapsular dissection of the inferior flap was performed during mastectomy. Biopsies were taken on each side of the dissection plane at 3 sites: median, medial and lateral. Several histological slides were prepared from each biopsy and examined for the presence of breast parenchymal or dispersed glandular tissue.

RESULTS

Three hundred and forty nine histological slides were examined, 185 from the resected breast side and 164 from the subcutaneous side. Ninety four percent of the slides from the breast side contained glandular tissue. Breast glandular tissue was found outside the dissection plane in 16 of 20 cases and in 33% of slides. This was sparse and dispersed in 69% of slides. A mean of 81% of slides from individual cases revealed glandular tissue inside and the absence of glandular tissue outside the dissection plane ("expected result"), demonstrating predominantly accurate juxtacapsular dissection.

CONCLUSION

This study demonstrated that accurate juxtacapsular inferior flap dissection leaves behind glandular breast tissue in a greater proportion of cases than any previous study. While this tissue is sparsely-distributed, surgeons should be aware of the occurrence of glandular breast tissue outside the juxtacapsular dissection plane in the majority of cases.

Determinants of optimal mastectomy skin flap thickness

Background

There is a limited evidence base to guide surgeons on the ideal thickness of skin flaps during mastectomy. Here the literature relevant to optimizing mastectomy skin flap thickness is reviewed, including anatomical studies, oncological considerations, factors affecting viability, and the impact of surgical technique and adjuvant therapies.

Methods

A MEDLINE search was performed using the search terms ‘mastectomy’ and ‘skin flap’ or ‘flap thickness’. Titles and abstracts from peer-reviewed publications were screened for relevance.

Results

A subcutaneous layer of variable thickness that contains minimal breast epithelium lies between the dermis and breast tissue. The thickness of this layer may vary within and between breasts, and does not appear to be associated with obesity or age. The existence of a distinct layer of superficial fascia in the breast remains controversial and may be present in only up to 56 per cent of patients. When present, it may not be visible macroscopically, and can contain islands of breast tissue. As skin flap necrosis occurs in approximately 5 per cent of patients, a balance must be sought between removing all breast tissue at mastectomy and leaving reliably viable skin flaps.

Conclusion

The variable and unpredictable thickness of the breast subcutaneous layer means that a single specific universal thickness for mastectomy skin flaps cannot be recommended. It may be that the plane between the subdermal fat and breast parenchyma is a reasonable guide for mastectomy flap thickness, but this may not always correspond to a subcutaneous fascial layer.

Long-term oncological results after 400 skin-sparing mastectomies

OBJECTIVE OF THE STUDY

Skin-sparing mastectomies (SSM) have gained acceptance among teams performing immediate breast reconstruction because this technique provides the best cosmetic outcome. Nevertheless, in France, concerns have been raised that limited skin excision during mastectomy could result in an increased risk of local recurrence especially in invasive breast cancer; many surgeons continue to have reservations regarding the oncologic safety of this operation. This is a retrospective, long-term follow-up study of 400 patients operated and followed by two oncoplastic surgeons.

PATIENTS AND METHODS

A total of 400 patients with breast cancer underwent SSM with immediate breast reconstruction from January 1, 1992 to December 31, 2002. The American Joint Committee on Cancer pathological staging was Stage 0 (41.5%), Stage I (33.25%), Stage II (16%), Stage III (7.5%), while 1.75% were non-stageable.

RESULTS

With a mean follow-up period of 88 months (range: 13-215 months), the locoregional recurrence rate was 3.5%, the rate of distant metastases was 13.5%, and 83% of patients have remained free of recurrent disease.

CONCLUSION

This study provides encouraging results suggesting that skin-sparing mastectomy is a safe and reliable option for the management of selected cases of women with invasive or in situ breast cancer.

Local heat preconditioning in skin sparing mastectomy: a pilot study

BACKGROUND

Experimental data has shown an association with a reduction of flap necrosis after local heat-application to a supraphysiological level resulting from the up-regulation of heat shock proteins, such as HSP-32. The proteins maintained capillary perfusion and increased tissue tolerance to ischaemia. The purpose of this translational study was to evaluate the effect of local heat preconditioning before skin sparing mastectomy and immediate breast reconstruction.

METHODS

A prospective non-randomised trial was performed from July 2009-April 2010. 50 consecutive patients at risk of skin flap necrosis (BMI >30, sternal-to-nipple distance>26 cm or breast size>C-cup) were included. Twenty-five patients were asked to heat-precondition their breast 24-h prior to surgery using a hot water bottle with a water temperature of 43 °C (thermometers provided), in three 30-min cycles interrupted by spontaneous cooling to room temperature. Skin flap necrosis was defined by the need for surgical debridement. LDI images were taken pre- and post-mastectomy to demonstrate an increase in tissue vascularity.

RESULTS

36% of women (n=25) without local heat-treatment developed skin flap necrosis, 12% developed skin flap necrosis in the treatment group, resulting in a 24% difference (n=25; p=0.047 (95%CI 1%-47%)). LDI scanning of the heated breast demonstrated an increase in vascularity compared to the contralateral non-heated breast. Median length of inpatient stay for treatment group was 4 days (95%CI(4, 7)), controls 8 days (95%CI(8, 9) (p=<0.001)).

CONCLUSIONS

The data suggests that in selected cases, local heat preconditioning is a simple and non-invasive method of reducing skin necrosis and length of hospital stay following skin sparing mastectomy.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12612001197820.

LEVEL OF EVIDENCE

II.

[Oncologic safety of skin-sparing mastectomy followed by immediate breast reconstruction: rate and localization of recurrences, and impact of reconstruction techniques]

INTRODUCTION

Oncological safety of skin-sparing mastectomy followed by immediate breast reconstruction is widely debated. Current evidence is relatively poor since it is based mostly on short-term follow-up data of highly selected patient populations.

AIM

Recurrence rates of a large cohort of non-selected patients, i. e. "all-comers" were analyzed during a 10-year follow up.

METHODS

Patient records and follow-up data of 253 consecutive cases treated with of skin-sparing mastectomy and immediate breast reconstruction between 1995 and 2000 were studied. During this time period "all-comers" policy was applied, which meant that all patients treated with mastectomy were offered immediate breast reconstruction regardless of tumour stage.

RESULTS

"All-comers" approach resulted in a large proportion of patients with more advanced disease. During the 112 months mean follow-up 8.2% locoregional, 2.9% local, 10.6% distal and 18.8% overall recurrence rates were detected. Breast cancer specific survival rate was 90.9%. Autologous breast reconstruction was applied more frequently in patients with higher tumour stage; therefore recurrence rate was higher compared to patients undergoing implant-based reconstruction.

CONCLUSION

Based on these long-term follow-up data skin-sparing mastectomy combined with immediate breast reconstruction is an oncologically safe treatment option. Therefore, application of "all-comers" policy for breast cancer patients treated with skin-sparing mastectomy followed by immediate breast reconstruction is feasible.

Update on breast reconstruction techniques and indications

Breast reconstruction is considered as part of the breast cancer treatment when a mastectomy is required. Implants or expanders are the most frequent techniques used for the reconstructions. Expander provides usually a better symmetry. A contralateral mastoplasty often is required to improve the symmetry. The nipple areola complex, which can be preserved in certain conditions, is usually removed and can be reconstructed in a second stage under local anesthesia. In case of radical mastectomy and/or radiotherapy, a musculocutaneous flap, such as rectus abdominis or latissimus dorsi autologous flaps, is required. When microsurgical facilities are available, free or perforator flaps respecting the muscle are preferred to decrease the donor site complications. In situ carcinomas or prophylactic mastectomy can be reconstructed immediately as well as invasive carcinoma according to the recent literature. Locally advanced breast cancer can be reconstructed after complete oncologic treatment. Radiotherapy of the thoracic wall is proposed in case of lymph node metastases, raising the discussion about the technique choice and the timing of the reconstruction. Plastic surgery procedures can improve the cosmetic results of the conservative surgery, also extending its indications and reducing both mastectomy and reexcision rates. Oncoplasty techniques are becoming more and more sophisticated, requiring the skill of trained plastic surgeons. Numerous publications confirm the psychosocial benefit resulting from the breast reconstruction.

Ten-year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction

BACKGROUND

The oncological safety of skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is debated owing to a presumed compromise in the completeness of mastectomy. Current evidence is poor as it is based mostly on short-term follow-up data from highly selected patients.

METHODS

A prospectively maintained institutional database was searched to identify patients who underwent SSM and IBR between 1995 and 2000. A retrospective review of medical records was carried out, including only patients with ductal carcinoma in situ and invasive breast cancer. During this time all patients treated with mastectomy were offered IBR regardless of tumour stage.

RESULTS

Follow-up data from 253 consecutive patients with IBR were reviewed. Patients with incomplete follow-up data and those undergoing SSM for recurrent disease following previous lumpectomy were disregarded, leaving 207 for analysis. Offering IBR to all women requiring mastectomy resulted in a large proportion of patients with advanced disease. During a median follow-up of 119 months, 17 (8·2 per cent) locoregional, six (2·9 per cent) local and 22 (10·6 per cent) distant recurrences were detected; the overall recurrence rate was 39 (18·8 per cent). Overall recurrence rate was associated with axillary lymph node metastasis (P = 0·009), higher stage (P < 0·001) and higher tumour grade (P = 0·031). The breast cancer-specific survival rate was 90·8 per cent (19 of 207 women died from recurrence).

CONCLUSION

Based on these long-term follow-up data, SSM combined with IBR is an oncologically safe treatment option regardless of tumour stage.

Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction: an update

The use of skin-sparing mastectomy (SSM) to facilitate breast reconstruction is increasing due to a wide acceptance of improved cosmetic outcomes and evidence of equivalence in oncologic outcomes. The rates of patients undergoing mastectomy for whom post-mastectomy radiotherapy (PMRT) will be recommended is increasing as evidence of decreased loco-regional recurrence and increased survival mounts. PMRT may adversely effect complication rates and cosmetic outcomes for patients undergoing immediate breast reconstruction and PMRT--although the evidence for this is methodologically flawed. This article summarises the above evidence and highlights a reconstructive algorithm that may be used to mitigate the possible deleterious effects of PMRT on results.

[Modern breast surgery]

Today, as a result of the complex and coordinated medical treatment of breast malignancies the long-term survival rate reaches 80%. Modern breast surgery plays a prominent role in the multidisciplinary treatment of breast tumors. Breast surgery in the 21st century simultaneously performs medical and aesthetic procedures on the same organ. Modern day breast surgery is founded on a complex view of breast malignancies, multidisciplinary cooperation, oncoplastic practice, and selecting the optimal surgery techniques, based on state of the art tools and a detailed treatment plan. Authors present the evolution of modern breast surgery; discuss the procedures such as mastectomy, breast conservation surgery, axillary lymph node removal, prophylactic mastectomy, as well as possible versions of immediate or delayed breast reconstruction.

Retrospective comparison of non-skin-sparing mastectomy and skin-sparing mastectomy with immediate breast reconstruction

Background. We compared Skin-sparing mastectomy (SSM) with immediate breast reconstruction and Non-skin-sparing mastectomy (NSSM), various types of incision in SSM. Method. Records of 202 consecutive breast cancer patients were reviewed retrospectively. Also in the SSM, three types of skin incision were used. Type A was a periareolar incision with a lateral extension, type B was a periareolar incision and axillary incision, and type C included straight incisions, a small elliptical incision (base line of nipple) within areolar complex and axillary incision. Results. Seventy-three SSMs and 129 NSSMs were performed. The mean follow-up was 30.0 (SSM) and 41.1 (NSSM) months. Respective values for the two groups were: mean age 47.0 and 57; seven-year cumulative local disease-free survival 92.1% and 95.2%; post operative skin necrosis 4.1% and 3.1%. In the SSM, average areolar diameter in type A & B was 35.4 mm, 43.0 mm in type C and postoperative nipple-areolar plasty was performed 61% in type A & B, 17% in type C, respectively. Conclusion. SSM for early breast cancer is associated with low morbidity and oncological safety that are as good as those of NSSM. Also in SSM, Type C is far superior as regards cost and cosmetic outcomes.

Role of nipple sparing mastectomy in modern breast surgery

Recently an increasing number of reports of clinical experience have been published on nipple-sparing mastectomy. By the preservation of uninvolved skin and the nipple areola complex, this surgical technique greatly facilitates immediate reconstruction and optimal aesthetic outcome. However, the procedure raises serious oncologic concerns regarding the risk of an occult or a newly formed primary tumor due to parenchyma left behind in the nipple and the retroareola. Despite the ever increasing popularity of the method, there is still no evidence based confirmation to it. According to data from scientific literature on nipple-sparing mastectomy, there is no straightforward consequence to be drawn on oncologic safety; therefore the procedure is not generally considered to be alternative to standard mastectomy. In the indication of risk reduction, justification of the intervention seems to be well supported, and is expected to foster a greater rate of acceptance of surgical prophylaxis in patients with higher risk diseases. The procedure should be carried out possibly in the framework of clinical trials, in well selected patients with suitable preoperative and postoperative examinations, applying precise techniques and adequate patient education, according to international guidelines. Further long-term results are needed to form a substantive expert opinion. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language. Orv. Hetil., 2011, 152, 1233–1249.

The Changing Face of Mastectomy (from Mutilation to Aid to Breast Reconstruction)

Breast cancer is the most common cancer in women. Primary treatment is surgery, with mastectomy as the main treatment for most of the twentieth century. However, over that time, the extent of the procedure varied, and less extensive mastectomies are employed today compared to those used in the past, as excessively mutilating procedures did not improve survival. Today, many women receive breast-conserving surgery, usually with radiotherapy to the residual breast, instead of mastectomy, as it has been shown to be as effective as mastectomy in early disease. The relatively new skin-sparing mastectomy, often with immediate breast reconstruction, improves aesthetic outcomes and is oncologically safe. Nipple-sparing mastectomy is newer and used increasingly, with better acceptance by patients, and again appears to be oncologically safe. Breast reconstruction is an important adjunct to mastectomy, as it has a positive psychological impact on the patient, contributing to improved quality of life.

Nipple Involvement in Breast Cancer: Retrospective Analysis of 2323 Consecutive Mastectomy Specimens

Breast cancer surgical options now include nipple-sparing mastectomy (NSM), but there has been much controversy regarding the oncologic safety of the preserved nipple. This study evaluates frequency and patterns of occult nipple involvement in a large contemporary cohort of patients, aiming to improve patient selection for NSM. A total of 2323 consecutive mastectomy specimens with grossly unremarkable nipples were evaluated by sagittal sections through the entire nipple and subareolar tissue. Sixteen different clinical and tumor parameters were examined to predict cancerous nipple involvement. Nipple involvement was noted in 331 of 2323 (14.2%) mastectomy specimens. Occult nipple involvement rate was 10.7% (248 cases). Occult nipple involvement usually occurs as ductal carcinoma in situ. In univariate analysis, patient age, tumor size, tumor-to-nipple distance, tumor central location, tumor type, lymph node status, lymphatic vascular invasion, histologic grade, estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2 (HER-2) amplification, and multicentric or multifocal tumor were associated with positive nipple involvement. By multivariate logistic regression analysis with the entire selection process, tumor size, tumor-to-nipple distance, central location, lymph node status, lymphatic vascular invasion, HER-2 amplification, and multicentric or multifocal tumor were shown to be associated with nipple involvement by carcinoma. Nearly 90% women undergoing mastectomy did not have occult nipple involvement. NSM may be a viable option in appropriate patient selection and setting. NAC preservation would be appropriate in HER-2 negative, axillary lymph node, and lymphatic vascular negative patients with small, solitary tumors located on the periphery of the breast.

Immediate reconstruction with implants in women with invasive breast cancer does not affect oncological safety in a matched cohort study

Physicians are still concerned about the oncological safety regarding immediate breast reconstruction (IBR) in breast cancer patients. This study aimed to evaluate possible differences between local, regional, and distant recurrences between women having implant-based reconstruction versus women operated with mastectomy alone. Secondary aims were to evaluate time to oncological treatment as well as disease-free and breast-cancer-specific survival. In a retrospective cohort designed study, 300 reconstructed patients with invasive breast cancer were matched with 300 patients from the population-based Regional Breast Cancer Register of the Stockholm-Gotland health-care region operated with mastectomy alone. They were matched for age, tumor size, nodal stage, and year of operation. Also included were patients treated with neoadjuvant chemotherapy and postoperative radiotherapy. The median follow-up for both the groups was 11.5 years (range 2-20). There were no significant differences in the local recurrence rate, 8.2% in the IBR group and 9.0% in the control group or in the regional recurrence rate, 8.2% versus 9.7%. Distant metastases occurred more frequently in the control group (27.1%) when compared to the IBR group (20.3%). There were no significant differences in time to treatment or in complications rate. Breast cancer mortality was 17% for the IBR group and 23% in the control group during follow-up. This long-term follow-up survey with a well-matched control group demonstrates that IBR with implants is safe to offer patients with invasive breast cancer without any negative effect on the oncological safety.

Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast. 2011;20:21-25. [PMID: 20619645 DOI: 10.1016/j.breast.2010.06.006]

Skin sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is not only oncologically safe but provides also significant benefits both cosmetically and functionally. The superiority of this technique can only be fully established, however, by developing a framework for minimising complications. The present study seeks to elucidate the key factors affecting outcome.

METHODS

Data for all skin sparing mastectomies with immediate autologous and implant based reconstructions, performed in a three year period (2006-2008) was retrospectively collated. Complications were classified into major and minor. Patients were excluded who had flap loss due to vascular complications.

RESULTS

The total number analysed was 151. 17.2% had major complications, 23% had minor and 61% had no complications. The Wise and the "tennis" incision had significantly higher rates of wound dehiscence when compared with the periareolar incision (p = 0.025, p = 0.098). There was no significant difference between diathermy or blade dissection techniques, or the use of subcutaneous adrenaline infiltration. Increasing BMI was associated with increased skin flap necrosis and wound dehiscence, and an excised breast mass of greater than 750 g and a sternal notch to nipple length of greater than 26 cm are associated as well with increased flap-related complications (p = 0.0002, p = 0.0049).

CONCLUSION

Factors such as Wise pattern and tennis racquet incision, BMI and breast mass and sternal notch to nipple length adversely affect skin sparing mastectomy flap morbidity. These factors should be factored in to patient selection and operative planning especially for obese and large breasted women undergoing skin sparing mastectomy with immediate breast reconstruction.

[Indications and technical procedures of mastectomy with immediate breast reconstruction]

Achieving a mastectomy occurs in one third of the acts of breast cancer surgery. In the present context, the increase in the diagnosis of early breast cancer, including widespread or multifocal forms, the possibility of a reconstruction at the same time is discussed. It will be proposed in a specific context, taking into account various factors: oncological (characteristics of the tumor, adjuvant treatments), clinical (smoking, comorbidity) and psychological (choice of the patient). The technique of mastectomy will be adapted to the indication and choice of reconstruction procedure. Including the preservation of the nipple-areola complex, or the skin envelope will be possible for some guidance. The reconstruction is possible with the use of breast implants, or musculocutaneous flaps or by the combination of both. Some of these techniques are associated with significant morbidity, and appropriate selection of procedure to the patient will guarantee a lower risk of complications.

Skin Sparing Mastectomy and Immediate Breast Reconstruction (SSMIR) for early breast cancer: eight years single institution experience

Background

Skin Sparing Mastectomy (SSM) and immediate breast reconstruction has become increasingly popular as an effective treatment for patients with breast carcinoma. The aim of this study was to evaluate the clinical outcome of skin sparing mastectomy in early breast cancer at a single population-based institution.

Methods

Records of ninety-five consecutive patients with operable breast cancer who had skin-sparing mastectomy and immediate breast reconstructions between 1995 and 2003 were reviewed. Patient and tumor characteristic, type of reconstruction, postoperative complications, aesthetic results and incidence of recurrence were analyzed.

Results

Mean age of the patients was 51.6(range 33–72) years. The AJCC pathologic stages were 0 (n = 51, 53.7%), I (n = 20, 21.1%), and II (n = 2, 2.1%). Twenty of the patients had recurrent disease (21.1%). The immediate breast reconstructions were performed with autologus tissue including latissimus dorsi musculocutaneous flap in 63 (66.3%) patients and transverse rectus abdominis myocutaneous (TRAM) flap in 4 (4.2%) patients. Implants were used in 28 (29.4%) patients. The average hospital stay was 7.7 days. Flap complication occurred in seven (10.4%) patients resulting in four (6%) re-operations and there were no delay in accomplishing postoperative adjuvant therapy. At a median follow-up of 69 months (range 48 to 144), local recurrence was seen in one patient (1.1%) and systemic recurrence was seen in two patients (2.1%).

Conclusion

Skin sparing mastectomy and immediate breast reconstruction for early breast cancer is associated with low morbidity and low rate of local recurrence.

A study of perfusion of the distal free-TRAM flap using laser Doppler flowmetry

The aim of this study was to characterise microcirculatory changes in the distal part of a flap and to evaluate whether measurement of the microcirculation may predict flap complications (FC). In this prospective study, 30 patients undergoing a delayed breast reconstruction were included. Perioperative data were recorded and with the laser Doppler flowmetry (LDF; Perimed) blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap. A lower blood flow was observed in zone IV of patients with flap complications compared to patients without flap complications (P=0.013). In addition, LDF demonstrated different flow trends in zone I compared to zone IV indicating a delayed opening of the choke vessels connecting the angiosomes in the distal part of the flap. The LDF has proven to be a useful investigative tool to monitor microcirculatory changes. In future studies it will be used to evaluate interventions aimed at decreasing distal ischaemia and reducing flap complications.

Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.

Surgical Management of Breast Cancer

OBJECTIVES

To review the surgical treatment options for breast cancer and breast reconstruction options following mastectomy.

DATA SOURCES

Clinical and research articles, textbook chapters, and clinical practice.

CONCLUSION

Advances have been made in the surgical treatment of breast cancer, and options for less invasive procedures are now available. Patients are often faced with difficult decisions when trying to choose the best treatment option.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an integral role in providing patients with the physical, educational, and emotional skills necessary to help them make appropriate surgical decisions and return to optimal health after their treatment.