Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction.

Abstract

The nipple is an uncommon site for breast cancer development, but the nipple-areola complex is routinely excised in breast cancer treatment. The authors evaluated the risks and benefits of nipple- or areola-sparing mastectomy with breast reconstruction.
The authors analyzed data on 115 consecutive nipple- or areola-sparing mastectomies with immediate tissue expander breast reconstruction performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer center. Nipple-sparing mastectomies were performed for prophylaxis (n = 75) or treatment of disease (n = 40).
Mean patient age was 45 years (range, 24 to 61 years) and mean follow-up time was 22 months (range, 2 weeks to 91 months). There were 115 nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), including 111 nipple-sparing and four areola-sparing mastectomies. On pathologic review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer, 11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision placement was periareolar and radial (n = 61), inframammary (n = 25), omega type (n = 14), customized to include a previous scar (n = 10), or transareolar (n = 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost because of occult disease (5.2 percent), and four nipples were lost because of wound-healing problems (3.5 percent).
In the authors' series of nipple- and areola-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be feasible in selected patients and should be the subject of additional investigation.

Full text

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BREAST
Nipple-Sparing Mastectomy and Immediate Tissue
Expander/Implant Breast Reconstruction
Constance M. Chen, M.D.,
M.P.H.
Joseph J. Disa, M.D.
Virgilio Sacchini, M.D.
Andrea L. Pusic, M.D.
Babak J. Mehrara, M.D.
Carlos A. Garcia-Etienne,
M.D.
Peter G. Cordeiro, M.D.
New York, N.Y.
Background: The nipple is an uncommon site for breast cancer development,
but the nipple-areola complex is routinely excised in breast cancer treatment.
The authors evaluated the risks and benefits of nipple- or areola-sparing mas-
tectomy with breast reconstruction.
Methods: The authors analyzed data on 115 consecutive nipple- or areola-
sparing mastectomies with immediate tissue expander breast reconstruction
performed in 66 patients from 1998 to 2008 at a single tertiary-care cancer
center. Nipple-sparing mastectomies were performed for prophylaxis (n ? 75)
or treatment of disease (n ? 40).
Results: Mean patient age was 45 years (range, 24 to 61 years) and mean
follow-up time was 22 months (range, 2 weeks to 91 months). There were 115
nipple- or areola-sparing mastectomies (48 bilateral and 19 unilateral), includ-
ing 111 nipple-sparing and four areola-sparing mastectomies. On pathologic
review, 20 breasts had ductal carcinoma in situ, 20 breasts had invasive cancer,
11 breasts had lobular carcinoma in situ, one breast had phyllodes tumor, one
breast had mucinous carcinoma, and 62 breasts were cancer-free. Incision
placement was periareolar and radial (n ? 61), inframammary (n ? 25), omega
type (n ? 14), customized to include a previous scar (n ? 10), or transareolar
(n ? 5). Of all 115 nipple- or areola-sparing mastectomies, six nipples were lost
because of occult disease (5.2 percent), and four nipples were lost because of
wound-healing problems (3.5 percent).
Conclusions: In the authors’ series of nipple- and areola-sparing mastectomies
performed for risk reduction or breast cancer, there was a low incidence of
occult disease (5.2 percent). Nipple- and areola-sparing mastectomy may be
feasible in selected patients and should be the subject of additional
investigation.(Plast. Reconstr. Surg. 124: 1772, 2009.)
N
construction after mastectomy is to create a new
breast that appears and feels as close as possible to
a natural breast. After a standard mastectomy,
however, the nipple-areola complex is excised.
Various methods have been developed to recon-
struct the nipple-areola complex, including local
flaps, skin grafts, composite grafts, banked carti-
ipple-sparing mastectomy is growing in
popularity because of its perceived aes-
thetic benefits.1–23The goal of breast re-
lage, and nipple-sharing procedures, to name a
few.24–40Despite this, patient satisfaction after nip-
ple-areola complex reconstruction can be disap-
pointing. In a one series, 36 percent of patients
undergoing breast reconstruction after mastec-
tomy reported dissatisfaction with their nipple re-
construction. Specifically, patients were unhappy
with the reconstructed nipple’s lack of projection,
color match, shape, size, texture, and position.41
Another common complaint after nipple-areola
complex reconstruction is complete or partial loss
ofnipplesensation.42,43Toimproveoutcome,plas-
tic surgeons have explored the possibility of pre-
serving the nipple in mastectomy and breast re-
From the Plastic and Reconstructive Service and the Breast
Service, Department of Surgery, Memorial Sloan-Kettering
Cancer Center.
Received for publication March 9, 2009; accepted June 29,
2009.
Presented at the 87th Annual Meeting of the American
Association of Plastic Surgeons, in Boston, Massachusetts,
April 5 through 8, 2008.
Copyright©2009bytheAmericanSocietyofPlasticSurgeons
DOI: 10.1097/PRS.0b013e3181bd05fd
Disclosure: None of the authors has a financial
interest to declare in relation to the content of this
article.
www.PRSJournal.com1772

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construction for decades.44Theoretically, nipple
and/or areola preservation, rather than recon-
struction, would best maintain native nipple
and/or areola shape, size, color, and sensation. In
this regard, the ideal nipple-areola complex re-
constructionwouldseemtoinvolvenoreconstruc-
tion at all.
Achievingimprovedbreastcosmesisbynipple-
areola complex preservation, however, has been
limited by concerns about surgical and oncologic
safety. Although the nipple is an uncommon site
for breast cancer development, the nipple-areola
complexisroutinelyexcisedinbreastcancertreat-
ment. Retrospective series analyzing the patho-
logic findings of mastectomy specimens report
widely different rates of nipple-areola complex
involvement that depend on many factors, includ-
ing tumor size, distance from the nipple-areola
complex, multicentricity, nuclear grade, and
lymph node status.45–57For example, in large tu-
mors that are in close proximity to the nipple, the
frequencyofnippleinvolvementaftermastectomy
can be as high as 37 to 68 percent.3,15,58In marked
contrast, nipple-areola complex involvement in
small and peripheral tumors is reported to be 1 to
12 percent.15,23,59,60More recent studies show an
acceptable level of risk in patients undergoing
nipple-sparing mastectomy for prophylaxis or to
remove small, peripheral tumors.12,17,61
This study evaluates our experience with nip-
ple- or areola-sparing mastectomy followed by im-
mediate tissue expander breast reconstruction
with respect to patient selection, incision place-
ment, and outcome. Surgical complications and
the oncologic safety of the nipple-sparing proce-
dure are also examined.
PATIENTS AND METHODS
This was a retrospective review of 115 consec-
utive nipple- or areola-sparing mastectomies with
immediate tissue-expander breast reconstructions
performed in 66 patients between 1998 and 2008
at Memorial Sloan-Kettering Cancer Center. Pa-
tients were screened for eligibility, and informed
that the current standard of care for both pro-
phylactic and therapeutic mastectomy was total
mastectomy with removal of the nipple-areola
complex.
Nipple-sparing mastectomy was presented as a
possible option for patients undergoing risk-re-
ducing surgery in one of the following settings:
strong family history of breast and ovarian cancer,
contralateral breast cancer, lobular carcinoma in
situ, or previous mantel radiation therapy for
Hodgkin lymphoma. Nipple-sparing mastectomy
was also presented as possible treatment option
for patients with ductal carcinoma in situ or mi-
croinvasive ductal carcinoma located greater than
1 cm from the areola on preoperative mammog-
raphy, ultrasound, or magnetic resonance imag-
ing and in patients with ductal carcinoma in situ
or microinvasive ductal carcinoma who had a pre-
viously performed biopsy of retroareolar tissue
proven to be negative for ductal or invasive car-
cinoma. Patients received counseling regarding
possible additional oncologic risks of nipple-are-
ola complex preservation and theoretical cos-
metic benefits. After this, patients were allowed to
choose between conventional total mastectomy
with second-stage nipple-areola complex recon-
struction or nipple-sparing mastectomy. In all
patients, immediate breast reconstruction with
tissue expanders was performed at the time of
the mastectomy.
A detailed chart review, and a review of data
from our prospectively maintained database, was
performed for each patient. The results were sys-
tematically recorded, with information compiled
on demographics, procedure, outcome, and com-
plications. Risk factors analyzed included disease
status, family history, adjuvant therapy, body mass
index,smokingstatus,timingofreconstruction,pre-
vious procedures, and medical comorbidities. We
alsoreviewedincisionplacement,cupsize,expander
type, use of acellular human dermis, and the in-
cidence of complications, including recurrent or
residual cancer, nipple or areola loss, scarring,
rippling, numbness, infection, seroma/hema-
toma, capsular contracture, delayed wound heal-
ing, and mastectomy flap necrosis. This study was
approved by the institutional review board of Me-
morial Sloan-Kettering Cancer Center.
RESULTS
Demographics
From 1998 to 2008 at Memorial Sloan-Ketter-
ing Cancer Center, 66 patients underwent 115
consecutive nipple- or areola-sparing mastecto-
mies with immediate tissue expander breast re-
construction. Mean patient age was 45 years
(range, 24 to 61 years) and mean follow-up time
was 22 months (range, 2 weeks to 91 months).
Patients underwent nipple- or areola-sparing mas-
tectomy for prophylaxis (n ? 75) or treatment of
ductal carcinoma in situ or microinvasive ductal
carcinoma (n ? 40). There were 115 nipple- or
areola-sparing mastectomies (48 bilateral and 19
unilateral), including 111 nipple-sparing and four
areola-sparing mastectomies. On pathologic re-
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view of the breasts that underwent nipple- or are-
ola-sparing mastectomies, 20 breasts had invasive
cancer (17.4 percent), 20 breasts had ductal car-
cinoma in situ (17.4 percent), 11 breasts had lob-
ular carcinoma in situ (9.6 percent), one breast
hadphyllodestumor(0.9percent),onebreasthad
mucinouscarcinoma(0.9percent),and62breasts
were cancer-free (53.9 percent). Of the 75 nipple-
sparing mastectomies that were performed for
prophylaxis, six breasts were subsequently found
to have invasive cancer or ductal carcinoma in situ
(8 percent) and 11 breasts had lobular carcinoma
in situ, a marker for disease (14.7 percent). Six
patients had prior radiation therapy for breast
cancer and one for Hodgkin disease (11 percent).
Surgical Procedure
For each procedure, mastectomy incision place-
ment was designed by the plastic surgeon in con-
sultation with the breast surgeon. In our series,
incision placement was periareolar with lateral ex-
tension(n?61),inframammary(n?25),omega-
type (n ? 14), customized to include a previous
scar (n ? 10), or transareolar (n ? 5) (Fig. 1). In
the majority of women, our preferred incision
was periareolar with a lateral extension. This
technique preserved breast contour and nipple-
areola shape for women with moderate sized
breastsandminimalptosis.Inaddition,thelateral
extensionallowedtheoncologicsurgeonaccessto
the breast, nipple-areola complex, and axilla for
both the mastectomy and sentinel lymph node
biopsy or lymph node dissection.
In all patients, breast reconstruction with tis-
sue expander placement was performed immedi-
ately following the nipple- and/or areola-sparing
mastectomy. Of the 115 nipple- or areola-sparing
mastectomies,111mastectomieswerenipple-spar-
ing (96.5 percent) and four mastectomies were
areola-sparing (3.5 percent) procedures. Of the
115 immediate tissue expander reconstructions,
48 reconstructions were bilateral (83.5 percent)
and 19 reconstructions were unilateral (16.5 per-
cent). There were 115 nipple- or areola-sparing
mastectomies performed in 66 patients. Of the 66
patients, 58 patients underwent tissue expansion
followed by subsequent permanent implant place-
mentinatwo-stagereconstruction(87.9percent);
eight patients underwent one-stage reconstruc-
tion (12.1 percent); and in 29 patients, acellular
human dermis was used (43.9 percent).
All tissue expanders were textured-surface, in-
tegrated-valve, moderate- or full-height styles. Ex-
pander sizes ranged between 300 and 500 cc and
were filled between 50 to 80 percent of the listed
volume at the time of surgery. Overexpansion
from 10 to 50 percent was accomplished during
the expansion phase to recruit more skin and
allow for an increased implant size, depending on
patient preference. Preservation of the complete
Fig. 1. Nipple-sparing mastectomy incision placement. (Above, left and center) Periareolar
and lateral incisions. (Above, right) Inframammary incision. (Below, left and center) Omega-
type incision. (Below, right) Transareolar incision. (One-time use of these figures granted by
Memorial Sloan-Kettering Cancer Center.)
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skin envelope and the frequent use of acellular
human dermis to cover the lower pole of the ex-
pander allowed for a greater initial fill volume
compared with traditional expander reconstruc-
tion after mastectomy. In this setting, initial ex-
pansion volumes are typically 20 to 40 percent of
the listed device volume.
For women with small breasts, an inframam-
mary incision was appropriate. An inframammary
incision allowed the scar to be camouflaged, al-
though resection of breast tissue superiorly and to
the axillary tail and in the superomedial aspect of
the breast could be more challenging. In women
with larger, more ptotic breasts, an omega-type
ellipticalincisionwasused.Thisallowedsomeskin
to be resected while preserving the nipple and/or
the areola. In patient 1, preoperative views (Fig. 2,
above) and reconstructive results (Fig. 2, below)
after bilateral immediate tissue expander place-
ment and a lateral incision in the right breast and
an omega-type incision in the left breast are
shown. Similar to the periareolar incision with
lateral extension, the omega-type elliptical inci-
siongavetheoncologicsurgeonwideaccesstothe
breast and axilla. In patient 2, preoperative views
(Fig. 3, above) and reconstructive results (Fig. 3,
below) after bilateral nipple-sparing mastectomy
with periareolar incisions for prophylaxis and sil-
icone implants are shown.
Complications
Of the 115 nipple- or areola-sparing mastec-
tomies with immediate tissue expander breast re-
construction, only six nipples had occult disease
(5.2 percent of mastectomy specimens; 9.1 per-
cent of patients). Of the six nipples with occult
disease,fivenippleshadresidualductalcarcinoma
in situ and one nipple contained infiltrative lob-
ular carcinoma. Two of the nipples with occult
disease had undergone nipple-sparing mastec-
tomy for prophylaxis. All six nipples with evidence
of carcinoma were excised.
Nineteen patients had wound-healing prob-
lems in the nipple-areola complex for reasons un-
relatedtoresidualcarcinoma.Infourpatients,the
Fig.2. Patient1.(Above)Preoperativeviewsbeforebilateralprophylacticmastectomy.(Below)Reconstructiveresultsafterbilateral
immediate tissue expander placement, with lateral incisions in the right breast and an omega-type incision in the left breast.
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nipple did not survive (3.5 percent). Of the four
patients with total nipple loss caused by wound-
healing problems, two underwent nipple-areola
complex reconstruction with a skate flap and full-
thickness skin graft; in one patient, the areola
survived and did not require reconstruction. In 15
patients,therewaspartialnippleorareolalossthat
did not require reconstruction (13 percent). Par-
tial-thickness nipple or areola loss included super-
ficial desquamation or eschar that healed with
conservative management (Fig. 4) to one nipple
that suffered 50 percent loss of nipple volume and
projection. Two of these patients were previously
irradiated. Thus, of 115 nipple- or areola-sparing
mastectomies, 25 nipples or areolas had total or
partial-thickness loss (21.7 percent); 15 nipples
were partially lost (13 percent), six nipples were
completely lost because of occult disease (5.2 per-
cent), and four nipples were completely lost be-
cause of wound-healing problems (3.5 percent).
Full-andpartial-thicknesslossofthenipple-areola
complex was not related to initial expander fill
volumebutwasmorecommoninthinmastectomy
skin flaps and larger, more ptotic breasts.
Finally, other complications after nipple- or
areola-sparing mastectomy included asymmetry
(n ? 5), capsular contracture (n ? 3), infection
(n ? 9), rippling (n ? 9), and hematoma (n ? 2).
Asymmetry and capsular contracture were cor-
rected at the second stage when the tissue ex-
pander was exchanged for a permanent implant.
In most cases, irregularities corresponded with
adjuvant radiation treatment. Of the nine infec-
tions, four were mild and managed with oral
antibiotics (44.4 percent), two required intra-
venous antibiotics (22.2 percent), and three de-
veloped purulent drainage leading to explanta-
tion of the expander (33.3 percent). Both cases
of hematoma required evacuation in the oper-
ating room (Table 1).
DISCUSSION
Inourseriesofnipple-andareola-sparingmas-
tectomies performed for risk reduction or breast
Fig. 3. Patient 2. (Above) Preoperative views before bilateral prophylactic nipple-sparing mastectomy. (Below) Reconstructive
results after periareolar incisions and bilateral reconstruction with silicone implants.
Plastic and Reconstructive Surgery • December 2009
1776