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Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon's experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon's experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.
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Alexandre Mendonça Munhoz, Eduardo Montag, José Roberto Filassi, Rolf Gemperli
Alexandre Mendonça Munhoz, Division of Plastic Surgery,
Hospital Sírio-Libanês, São Paulo, SP 01239-040, Brazil
Eduardo Montag, José Roberto Filassi, Cancer Institute of São
Paulo, University of São Paulo School of Medicine, São Paulo,
SP01246-903, Brazil
Rolf Gemperli, Plastic Surgery Division, University of São Paulo
School of Medicine, São Paulo, SP 01246-903, Brazil
Author contributions: Munhoz AM and Montag E collected
and analyzed the data; Munhoz AM interpreted the data and
wrote the paper; Filassi JR and Gemperli R analyzed and inter-
preted the data.
Correspondence to: Alexandre Mendonça Munhoz, MD,
Division of Plastic Surgery, Hospital Sírio-Libanês, Rua Mato
Grosso, 306 cj.1705-1706, Sao Paulo, SP 01239-040,
Telephone: +55-11-96098850 Fax: +55-11-32551769
Received: December 18, 2013 Revised: January 24, 2014
Accepted: May 15, 2014
Published online: August 10, 2014
Nipple-sparing mastectomy (NSM) is a safe technique
in patients who are candidates for conservation breast
surgery. However, there is worry concerning its onco-
logical safety and surgical outcome in terms of post-
operative complications. The authors reviewed the
literature to evaluate the oncological safety, patient
selection, surgical techniques, and also to identify the
factors inuencing postoperative outcome and compli-
cation rates. Patient selection and safety related to NSM
are based on oncological and anatomical parameters.
Among the main criteria, the oncological aspects in-
clude the clinical stage of breast cancer, tumor charac-
teristics and location including small, peripherally locat-
ed tumors, without multicentricity, or for prophylactic
mastectomy. Surgical success depends on coordinated
planning with the oncological surgeon and careful pre-
Immediate nipple-areola-sparing mastectomy
reconstruction: An update on oncological and reconstruction
WJCO 20th Anniversary Special Issues (2): Breast Cancer
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DOI: 10.5306/wjco.v5.i3.478
World J Clin Oncol 2014 August 10; 5(3): 478-494
ISSN 2218-4333 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved.
World Journal of
Clinical Oncology
478 August 10, 2014
Volume 5
Issue 3
operative and intraoperative management. In general,
the NSM reconstruction is related to autologous and
alloplastic techniques and sometimes include contra-
lateral breast surgery. Choice of reconstructive tech-
nique following NSM requires accurate consideration
of various patient related factors, including: breast
volume, degree of ptosis, areola size, clinical factors,
and surgeon’s experience. In addition, tumor related
factors include dimension, location and proximity to the
nipple-areola complex (NAC). Regardless of the fact
that there is no unanimity concerning the appropriate
technique, the criteria are determined by the surgeon’
s experience and the anatomical aspects of the breast.
The positive aspects of the technique utilized should
include low interference with the oncological treatment,
reproducibility, and long-term results. Selected patients
can have safe outcomes and therefore this may be a
feasible option for early breast cancer management.
However, available data demonstrates that NSM can
be safely performed for breast cancer treatment in se-
lected cases. Additional studies and longer follow-up
are necessary to dene consistent selection criteria for
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Breast reconstruction; Skin-sparing mas-
tectomy; Nipple-sparing mastectomy; Outcome; Com-
plications; Silicone breast implants; Tissue expanders;
Oncoplastic surgery
Core tip: In selected patients, nipple-sparing mastec-
tomy (NSM) has allowed an adequate oncologic control
with satisfactory aesthetic outcome. In addition, utiliz-
ing the native breast skin optimizes the aesthetic out-
come of the reconstructed breast and minimizes post-
mastectomy deformity. The satisfactory results are due
to a close collaboration with the oncological surgical
ed the technique for benign diseases, however he did not
report the procedure for oncological objectives or as a
risk-reduction alternative[10,11]. Recently, there has been an
increase in clinical experience studies of NSM for breast
cancer prophylaxis or early cancer treatment, evidencing
revived interest in this surgical procedure[12-30,33-44]. In fact,
there is evidence that NSM provides aesthetic advantages,
with reduced need for further surgery and NAC recon-
struction[15,17,20-22,29,33-39,44-48]. However, it is important to
emphasize that most of these clinical series do not have
sufficient follow-up, thus definite conclusions based on
the present data is precipitated. In addition, to date there
have been no controled clinical trials evaluating the onco-
logical effectiveness of nipple-sparing mastectomy (NSM)
vs traditional SSM surgery. In spite of the controversies
involving risk of local relapse, some current clinical stud-
ies have shown that the NSM is a safe procedure for se-
lected cases[11,14-16,18,23-27,29,30,33-39,44,47,48].
Two independent reviewers have evaluated titles and ab-
stracts without language restrictions to assess eligibility in
terms of outcome measures and study design. A literature
search was carried out up to October 2013 to identify
studies of breast cancer patients submitted to NSM and
determine if any technique of immediate reconstruction
was recorded. In an attempt to minimize the omission of
potentially relevant clinical studies, we also reviewed the
reference lists of included studies and relevant reviews
for additional eligible articles. Potential studies were iden-
tied by searches of MEDLINE and PubMed databases
using the terms “Nipple-Areola Sparing Mastectomy”,
“Total Skin-Sparing Mastectomy”, “Subcutaneous Mas-
tectomy” and “Immediate Reconstruction”. Studies iden-
tied were screened for those that focused on techniques,
surgical and oncological outcomes after NSM reconstruc-
tion and references of each study were further investi-
gated to include all relevant published data. All types of
reconstruction techniques were included (tissue expander,
implant, autologous tissue, and combination of methods)
and compared.
A total of 440 potential articles were identied during
the primary evaluation. After appraisal of the inclusion
criteria, 265 articles were identified for potential inclu-
sion and reviewed in detail. A total of 150 articles were
excluded, leaving 115 articles to form the basis of this
Oncological safety / patient selection
The main criteria include the clinical stage of breast
cancer and tumor aspects[11,15,27,37-39]. From the oncologi-
cal point of view, the NAC is resected because of the
traditional concept that the adjacent ducts may contain
tumor cells and the possibility of local recurrence[40,41].
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
479 August 10, 2014
Volume 5
Issue 3
team in terms of incision selection and mastectomy ap
dissection. In general, choice of reconstructive proce-
dure requires careful consideration of various patient
related factors, including: breast volume, degree of
ptosis, areolar size, patient preference and expectation,
and surgeon experience. With careful patient selection
and well-planned surgical technique, NSM can provide
satisfactory outcomes with acceptable complication
rates. However, available data demonstrate that NSM
can be safely performed for breast cancer treatment in
selected cases. Although NSM reduces the psychologi-
cal trauma associated with NAC resection, the oncologic
safety as well as functional and aesthetic outcomes
needs additional investigation. Thus, additional clinical
studies and longer follow-up are necessary to define
consistent selection criteria for NSM.
Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate
nipple-areola-sparing mastectomy reconstruction: An update
on oncological and reconstruction techniques. World J Clin
Oncol 2014; 5(3): 478-494 Available from: URL: http://www. DOI: http://dx.doi.
Early breast cancer treatment has advanced greatly in re-
cent years. The introduction of skin-sparing mastectomy
(SSM) technique has improved the aesthetic outcome of
oncological breast surgery and immediate reconstruc-
tion[1]. In fact, breast reconstruction following mastec-
tomy can result in a prominent scars and a paddle of
skin that is of a different color. Thus, the SSM involves
en-bloc resection of the glandular tissue, nipple-areola
complex (NAC), and the skin overlying superficial tu-
mours[2-5]. Simultaneously, the native breast skin envelope
and infra-mammary fold are preserved therefore facilitat-
ing the reconstruction procedure. Utilizing the breast skin
envelope optimizes the contour of the breast, resulting in
a satisfactory aesthetic outcome and minimizing scarring
and post-mastectomy deformity[6-9].
Recently, an argumentation has advanced about the
opportunity of extending conservation of the skin to
include the NAC[10-29]. In fact, although breast reconstruc-
tion following SSM may offer aesthetic advantages over
mastectomy, removal of the NAC significantly impacts
on the aesthetic outcome. Some surgical techniques have
been developed to repair the NAC, including local skin
flaps, skin grafts, and nipple-sharing procedures[30-31].
However, different surgical stages are usually necessary
to achieve an acceptable aesthetic result and sometimes
with an unpredictable outcome[30-32]. In one clinical series,
Jabor et al[32] evaluated the satisfaction following NAC
reconstruction and observed that almost 36% of patients
mentioned dissatisfaction.
First described by Freeman in the 1960s as a subcuta-
neous mastectomy with NAC sparing, the author indicat-
In addition, some clinical series observed that nipple in-
volvement in mastectomy specimens ranges from 0% to
58%[12,38,42-54] (Table 1). One might surmise that this wide
range is chiey due to divergences in techniques used for
pathology tests of the breast specimens, differences in
technique and subgroup of patient populations. In fact,
early anatomical studies proposed by Sappey described a
centripetal lymphatic drainage toward the areolar plexus,
thus justifing the rationale of NAC resection[15,44]. Con-
trarily, recent anatomical studies demonstrated a lymphat-
ic drainage to the deep pectoral plexus[44,55,56].
Concerning the clinical aspects, recent studies have
noted that the risk of tumor involvement of the NAC
has been magnied[38,41-43]. Thus, some clinical series have
demonstrated that the NSM is a safe technique for some
group of patients[11,14-16,18,19,23-27,29,30,33-39,44,57]. In fact, some
studies have considered NSM safe in patients with pe-
ripherally located tumors, small, without multicentricity,
or for risk reduction[24]. Although there is no unanimity
regarding the selection criteria, the major part of studies
include tumor size up to 3 cm, lack of clinical involve-
ment of the NAC and tumor to nipple distance greater
than to 2 cm. In addition, patients with clinical axillary
node involvement; whose tumors are centrally located;
who have inflammatory breast cancer, or Paget disease
are not candidates for NSM.
In a clinical experience of 286 SSM specimens, Lar-
onga et al[38] observed that 5.6% were found to contain tu-
mor in the NAC and did not dene signicant differenc-
es between groups regarding tumor size and histological
subtype. However, sub-areolar tumor location and multi-
centricity were important risk factors for NAC involve-
ment. Based on these ndings, the authors observed that
in patients with negative axilla and tumors situated on the
periphery, the probability of an occult tumor is less than
2%. Similarly, Vyas et al[42] in a clinical series of 140 mas-
tectomies analyzed whether NAC correlated with areola-
tumor distance, tumor size, nodal status and lymphatic
embolization. In this sample, the authors also observed
tumour size and nodal positivity as a potential risk factor
for NAC involvement. Correspondingly, Simmons et al[43]
analyzed 217 mastectomy specimens and evaluated tumor
involvement of the NAC. Concerning the NAC involve-
ment, the overall frequency was 10.6% and comparisons
of patients with tumors < 2 cm with tumors 2 cm did
not present a signicant difference. The authors observed
that only 6.7% of small tumors with up to two positive
lymph nodes only had NAC involvement. For tumors
located in central quadrants, the NAC was involved in
27.3% of cases. Contrarily, for those located in any of the
four quadrants, the NAC was compromised in only 6.4%
of cases. Gerber et al[57] in a series of 112 NSMs, evalu-
ated patients whose tumors were more than 2 cm from
the NAC. The frozen sections of the subareolar tissue
were negative for tumor in 54.5% of cases, thus enabling
NAC preservation. During the follow-up, 5.4% local re-
currences (LR) occurred in patients who underwent SSM
compared with 8.2% of 134 patients who had undergone
conventional mastectomy during the same follow-up.
Regolo et al[19] in a clinical study of 219 mastectomies ob-
served that 20% of NACs were compromised by tumor,
consisting of 9.4% of stage 1-2 tumors and 30% of stage
tumors. Concerning the tumor location, the NAC was
compromised in 2.5% of peripheral tumors and in 68%
of central quadrants. The authors failed to observe any
cases of local relapse in patients undergoing NSM after
an average of 16 months follow-up (Table 2).
Caruso et al[16] indicated NSM in patients with tumors
that were peripherally situated. Their study included 50
patients with a 12% overall recurrence rate. Similarly, Sac-
chini et al[18] evaluated patients who had NSM with recon-
struction for either risk reduction, treatment of cancer, or
both. With a median follow-up of 24 months, two breast
cancer patients and two patients who had NSM for pro-
phylaxis presented a local recurrence outside of the NAC.
Based on this clinical experience, the authors concluded
that the risk of local relapse is low and the procedure is
feasible in the risk-reducing and breast cancer-treatment.
Munhoz et al[33] evaluated 158 consecutive patients
submitted to NSM. In almost 35 percent of patients the
procedure was indicated for cancer prophylaxis including
high-risk lesions, prophylactic, familial history and carri-
ers of the BRCA1 or BRCA2 mutation. In the remaining
breast cancer patients, almost 75% of tumors measured
2 cm or less (T1) and the majority were stage 0 and I.
Similarly as observed by other authors, the present study
also included a few stage III breast carcinomas; however
in the preoperative period these patients were staged as
earlier-stage carcinoma[9,58]. Additionally, the authors ex-
cluded patients with NAC inltration, NAC bleeding or
with the tumor at less than 5 cm from the NAC. Consid-
ering these parameters, the authors believe that NSM is
feasible with low local recurrence. With a mean follow-up
of 65.6 mo, local recurrence rate was 3.7% and the inci-
dence of distant metastases was 1.8%.
In a comprehensive review, Tokin et al[24] observed
that the local recurrence following NSM was between
0%-20%, with studies varying widely in inclusion criteria
and follow-up period. Boneti et al[26] reported in a series
480 August 10, 2014
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Table 1 Occult neoplastic involvement of the nipple areola complex
Ref. Year
Nipple areola complex
involvement (%)
Santini et al[45] 1989 1291 12
Menon et al[46] 1989 33 58
Verma et al[47] 1997 26 0
Vyas et al[42] 1998 140 16
Laronga et al[38] 1999 246 5.6
Simmons et al[43] 2002 217 10.6
Loewen et al[48] 2008 302 10
Rusby et al[53] 2008 130 24.6
Banerjee et al[49] 2008 219 20
Voltura et al[50] 2008 34 5.9
Pirozzi et al[51] 2010 50 28
Reynolds et al[52] 2011 29 7
Wang et al[54] 2012 787 7
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
two-stages approaches.
One-stage approach: With one-stage approach both
procedures (breast cancer treatment/risk reduction and
reconstruction procedures) are associated in one opera-
tive setting. Additionally, the emotional benet of having
begun reconstruction at the time of NSM procedure may
decrease the impact of the loss of the breast. In fact,
Sahin et al[60] in a series of 21 bilateral prophylactic NSM
due to higher risk for cancer indicated the one stage ap-
proach and simultaneous breast reconstruction using
submuscular silicone implants. According to the authors,
better projection and shape may be achieved with serial
expansion of the submuscular pocket, but this has to be
weighed against the morbidity associated with two surgi-
cal procedures. In their clinical experience, a one-stage
procedure using high-profile implants resulted in very
good projection while avoiding the morbidity of a sec-
ond surgery.
Other centers indicated both approaches accord-
ing to the quality and the width of the remaining breast
skin ap. Chen et al[30] in a series of 115 NSM evaluated
the risks and benefits of the procedure associated with
immediate breast reconstruction. In all patients, recon-
struction with tissue expander or silicone implant was
performed immediately following the NSM. Of the 66
patients, 58 underwent tissue expansion followed by im-
plant placement in a two-stage reconstruction (87.9%)
and eight patients underwent one-stage reconstruction
(12.1%). According to the authors, nineteen patients had
wound-healing problems. Full and partial necrosis of the
NAC was not associated to initial expander volume but
was more prevalent in thin aps and larger breasts.
Although NSM and immediate implant reconstruc-
tion can be accomplished in a single stage, this is not
the rst option in some cancer centers[30]. In fact, Chen
et al[30] emphasized that with two the stage approach it is
possible to have a better control over the NSM skin ap.
First, some aspects relating to implant asymmetry can be
treated at the time of the second stage. Second, by limit-
ing the volume of the expander such that the skin ap is
not redundant but also not under tension, the risk of ne-
crosis is reduced. Finally, patients usually desire a volume
change, and starting the reconstruction with a two stage
of 281 NSM with 25.3 mo mean follow-up, a 4.6% lo-
cal recurrence rate. Jensen et al[27] published results from
149 patients without local recurrences at a mean 5-years
In a recent review, Mallon et al[59] quantied the inci-
dence of occult NAC cancer and identified the factors
influencing occult nipple malignancy, local recurrence
rates, and complication rates. According to the authors,
the overall nipple (0.8 percent) and flap (3.4 percent)
recurrence rates were similar to those reported after mas-
tectomy and conservative breast surgery. However, care
must be taken to distinguish that follow-up periods for
NSM clinical studies are briefer than those for mastec-
tomy and partial mastectomy. For denitive conclusions,
a longer and similar follow-up is necessary, as the greater
part of recurrences occur within 5 years.
Therefore, it would appear oncologically safe to per-
form NSM, provided the tumor is not close to the NAC,
small, peripherally located, without multicentricity and a
frozen section protocol is performed. Although various
clinical series including SSM and NSM aided in the selec-
tion of patients for NSM using tumor to NAC distance
values, the ideal tumor to NAC distance has yet to be
claried, since the total number of patients analyzed in
these clinical series is insufficient and requires valida-
tion[41,59]. Additionally, patients must be informed that
NAC resection may still be necessary if residual tumor is
identied on frozen sections of the subareolar tissue or
denitive histology.
Timing: One stage x two stage approach
NSM may be planned in one setting with immediate
reconstruction (one-stage approach)[39,57,60], or in two
settings with partial glandular resection or NAC autono-
mization followed by additional breast tissue resection
and total reconstruction weeks to months afterwards
(two-stages approach)[30,34,39,61-65].
Preoperative planning should include the breast ptosis
and volume and mostly addressing singular reconstruc-
tive requirements, enabling each patient to receive an
individual “custom-made” planning. In addition, an in-
depth discussion concerning alternatives for NSM recon-
struction should be undertaken with the patients and her
family, including the risks and positive aspects of one vs
481 August 10, 2014
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Table 2 Clinical outcome and local recurrences following nipple-sparing mastectomy
Ref. Year
Stage Follow-up (mo) Nipple areola complex recurrence Local recurrence
Gerber et al[25] 2009 61 0- 59 1.6 5.4
Garcia-Etienne et al[15] 2006 42 0- 10.5 0 0
Bistoni et al[106] 2006 10 0- 36 0 0
Voltura et al[50] 2008 51 0- 18 0 5.9
Crowe et al[14] 2004 54 0- 41 0 0
Petit et al[104] 2005 579 0-I 19 0 0.9
Sacchini et al[18] 2006 192 0- 24.6 0 3
Paepke et al[103] 2009 109 0- 34 0 1.83
Babiera et al[107] 2010 54 0- 15 0 0
Benediktsson et al[105] 2008 216 0-156 0 8.5
Munhoz et al[33] 2013 158 0- 65.6 0 3.7
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
approach allows the surgeon to customize the outcome
to patient preference.
In spite of these aspects, for some group of patients
the one-stage approach can be advantageous. In fact,
patients with small breasts, without ptosis and cardio-
vascular clinical diseases are the best candidates for one-
stage NSM. Caruso et al[16] considered NSM in patients
with small to moderate-sized breasts with moderate to
minimal ptosis and a healthy breast skin. Similarly, in a
systematic review Endara et al[39] examined current trends
with NSM, including selection criteria, incision choice,
and reconstructive techniques. In the major part of the
cases, NSM requires no skin resection, however with in-
creasing breast volume (> 500 g) or breast ptosis, higher
rates of NAC or breast skin ap necrosis are expected. In
addition, low BMI and minimal ptosis were consistently
used to screen patients for NSM in these studies.
Conversely, with the one-stage approach the surgical
time can be lengthened and potential complications of
the NSM (e.g., skin/NAC necrosis, dehiscence, infection)
can adversely influence the postoperative outcome. In
addition, the procedure can be compromised by posi-
tive margins, especially in the sub-areolar region. In fact,
Mallon et al[59] in a recent comprehensive review dem-
onstrated that the greater part of the NSM studies per-
formed biopsy of the retroareolar tissue separately from
the mastectomy specimen. Concerning the technique,
some studies used frozen section analysis, however, this
technique has a false-negative rate as high as 8.7 percent
according to the present review. Therefore many cancer
centers await denitive pathologic evaluation of sub-are-
olar specimens before deciding on NAC resection. Thus,
it is advocated that all patients submitted to one stage
therapeutic NSM have a retroareolar sampling. In addi-
tion, these patients must be informed that the NAC may
need to be ultimately resected if result of the retroareolar
biopsy is compromised.
Two-stage approach: With two-stage approach, the
surgical process is less extensive than NSM and immedia-
te reconstruction in one operative setting. Some patients
are so distressed by their cancer diagnosis, that they are
not able to cooperate in reconstructive decisions. Addi-
tionally, some potential complications of the NSM and
reconstruction techniques (e.g., skin necrosis, dehiscence,
infection) can unfavorably defer the adjuvant therapy.
However, while the rationale for this approach is reason-
able, the addition of a different surgical stage may intro-
duce possibilities for complications[65].
First proposed by Palmieri et al[66], the two-stage con-
cept of delayed NSM had the objective of complete re-
moval of all breast tissue, including the lactiferous ducts.
According to the authors, the first stage involves NAC
autonomization by performing a periareolar incision to
detach the ductus from the nipple. The second stage is
then performed 2-3 wk later. The authors observed one
case of NAC necrosis that occurred during the NAC
autonomization, delaying the NSM for 6 wk to allow
complete revascularization with a satisfactory outcome.
Similarly, Jensen et al[67] indicated the two-stage approach
with NAC surgical delay in 20 patients who were at high
risk for NAC necrosis following NSM. The authors per-
formed the delay technique 7-21 d prior to NSM mas-
tectomy. Sub-areolar biopsy was performed at the time
of the delay procedure and if the biopsy revealed malig-
nancy, the NAC was removed at the time of NSM. All of
the NAC survived and in 2 patients the subareolar biopsy
was positive and 3 NAC were removed.
Another important point is related to the possibility
of another stage to improve the aesthetic outcome[30,34].
In fact, Blechman et al[34] in a series of 55 NSM per-
formed in 29 consecutive patients evaluated the technical
aspects and outcome. After tissue expansion the implant
volume can be selected during the second stage without
causing ap tension. Also, this strategy provides an op-
portunity to rene the breast contour such as by fat graft-
In the greater part of the clinical series, NSM are
related to patients with relatively small, minimally ptotic
breasts or for risk reduction[14,39,61,62]. However, the NSM
reconstruction of large and/or ptotic breasts poses a
more troublesome challenge than the NSM of small
sized breasts because of an excessively large skin ap[33].
In addition, the Wise-pattern skin excision best addresses
this excess skin but is associated with a high incidence of
ap necrosis with subsequent reconstruction failure[22,33].
Munhoz et al[33] in a series of 158 patients submitted to
NSM observed a signicantly higher incidence of com-
plications in the obese and larger specimen group. This
aspect can be partially explained by a decreased perfusion
of the relatively large skin flaps that result from SSM
in much larger breasts. According to the authors, after
adjusting for other risk factors (BMI, weight of breast
specimen), the probability of complications tends to be
higher for the Wise pattern with superior pedicle incision
Although large breasts and severe ptosis may repre-
sent a contraindication for NSM, surgical strategies based
on the two-stage concept were planned to correct the
ptosis followed by NSM in a second stage. Introduced
by Spear et al[61] the NSM staged procedure includes pa-
tients with large or ptotic breasts and candidates to NAC
preservation. In fact, the authors observed that although
there are breasts that are too large to be considered for
a NSM, it is possible to extend the indications by using
the two stage approach and reducing the breast volume
and ptosis previously. Thus, the main objective in these
sub-group of patients is to preserve the oncological ob-
jective of the NSM (therapeutic or risk reduction) while
expanding the aesthetic outcome and minimizing compli-
cations. For this objective, some authors divided the one-
stage Wise-pattern skin excision into a two-stage proce-
dure[61,63,64]. In the rst stage, the mastopexy or reduction
mammoplasty is performed, keeping periareolar dermis
preserved to maintain the adequate NAC blood supply at
the time of the future denitive NSM. At the time of the
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Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
second stage, care must be taken to guarantee consistent
ap thickness in order to avoid damage to the skin ap
blood supply.
Liu et al[63] in a series of 12 patients achieved success-
ful outcome using the two staged Wise-pattern excision.
In the rst stage, the NSM and reconstruction were per-
formed using a vertical excision. In the second stage, the
redundant skin at the inframammary fold was excised,
tightening the breast skin envelope vertically. According
to the authors, the addition of the two staged incisions
recreates the Wise pattern, breaking up the T point into
two straightforward primary closures. Similarly, Spear et
al[61] reported a successful two-stage NSM in 15 patients
(24 breasts). All patients underwent NSM after masto-
pexy or reduction (71% prophylactic and 29% therapeu-
tic) with an average follow-up of 13 months. Four of the
24 operated breasts (17 percent) presented a complica-
tion. Besides the satisfactory outcome, it is important to
emphasize that although the two-stage NSM is acceptable
in the prophylactic group, patient selection is somewhat
more complex in the group with breast cancer. Thus, the
two-staged procedure must be correctly planned so that
it does not signicantly delay the oncological treatment
in this patient population. Yacoumettis in a retrospective
study of 52 patients evaluated the results of bilateral sub-
cutaneous mastectomy for breast cancer prophylaxis[64].
All reconstructions were completed in two-stages with
tissue expanders followed by textured gel filled silicone
implants. According to the authors and during the aver-
age follow-up of 7.2 years, no cases of invasive cancer
were observed, and the aesthetic outcome was considered
Thus, the two-stage concept can be, in theory, advan-
tageous when compared to the one stage NSM. How-
ever, as we observed in any procedure this approach can
present some limitations. The main negative aspects are
related to some technical difculties, i.e., scar tissue and
brosis. Additionally, the procedure can be time consum-
ing and demanding additional costs, which can represent
some limitations to the insurance coverage and resource
implications for community hospitals.
Incision selection
Numerous incisions have been described by a variety of
designs incorporating a periareolar approach, or other
variations in the shape around the NAC[11-16,18-22,30,33-37,39,59,
61,63,66-68]. Although the incision types vary with congura-
tion, the impasse of the access incision with no compli-
cations has drawn attention in the great part of the stud-
ies[20,25-28,30,33] (Figure 1).
A critical survey shows that the procedure is nor-
mally performed by numerous approaches, but the
greater part more than one type of incision is per-
formed[11-16,18-22,30,33-37,39,59,61,63,66-69]. In fact, Endara et al[39]
analyzed 48 NSM studies, of which 41 described details
related to the type of NSM incision. A total of 15 diverse
approaches were described and the greater part of the
studies (70 percent) more than one type of incision was
indicated. According to the authors, the most common
incision described were radial, followed by periareolar,
inframammary, mastopexy, and transareolar (Figures 2-4).
The radial incision is one of the most performed
techniques for NSM. Endara et al[39] reported that this in-
cison represented almost 46% of all incisions performed.
Stolier et al[20] in a series of 82 NSM for risk reduction
and cancer treatment described that the most common
483 August 10, 2014
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Figure 1 Schematic representation of nipple-sparing mastectomy incisions. A: Radial lateral incision; B: Periareolar with lateral extension; C: Hemi-periareolar
(superior and inferior); D: Transareolar; E: Circumareolar (periareolar total); F: Periareolar with vertical extension; G: Circumareolar (periareolar total) with vertical ex-
tension; H: Wise-pattern mastectomy.
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
incisions utilized were related to the radial incision and
a lateral incision beginning from outside the NAC. Ac-
cording to the authors, this incision allowed an adequate
exposure to all regions including the axillary tail and the
internal thoracic vessels for free flap anastomosis. Col-
well et al[70] performed an inferolateral approach with the
incision located in the lateral quadrant. Similarly, Chung
and Sacchini evaluated NSM incisions, which the greater
part associated the periareolar to the radial incisions[65].
The same group reported NSM through different inci-
sions and the periareolar incision with lateral extension
was used in 42% of cases[11]. The authors mentioned a
satisfactory exposure as advantages of the use of the
radial extensions. Compared to other incisions, compli-
cations were observed in 67% of cases with an inferior
lateral incision (inframammary fold extended laterally).
Wijayanayagam et al[71] in a series of 64 NSMs performed
in 43 patients evaluated the technical aspects and surgical
outcome. Using different types of incisions, the authors
observed that the radial incision provided the best ap-
proach and had the greatest likelihood of maintaining
viable NAC without necrosis, which was observed in
almost 97% of the sample. Despite the benefits, some
authors do not advocate this approach due to aesthetic
disadvantages. In fact, this technique creates a scar that is
especially visible in the oblique and prole views[60].
The periareolar incisions are the second most per-
formed techniques for NSM. In fact, Endara et al[39]
reported that the periareolar approach represent almost
27% of all incisions performed for NSM. The main
benets are related to scar camouage with a more sat-
isfactory outcome. Despite its advantages, the periareo-
484 August 10, 2014
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Figure 2 Nipple-sparing mastectomy/inframammary incision. A and B: A 44-year-old patient with an invasive ductal carcinoma in the right breast (1.4 cm) and
a familial history of breast cancer; C and D: Nipple-sparing mastectomy preoperative planning was based on a bilateral through a inframammary approach and im-
mediate reconstruction with biodimensional implant-expander (Allergan 150 SH, 285 cm3). Intraoperative frozen sections demonstrated nipple-areola complex free of
tumor; E and F: Five years postoperative appearance with a very good outcome.
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
lar incision is not adequate for all patients candidate to
NSM. In fact, the more suitable indication is in patients
with small breasts with an adequate areola diameter. A
limited exposure and difculty in breast aps dissection
are commonly observed in small areola patients and in-
experienced breast surgeon. For patients with large areola
diameter without breast ptosis, a hemicircumareolar inci-
sion is usually indicated. Another important indication
is the presence of a marked color transition between
the NAC and the breast skin and small/medium volume
breasts (cup size A-B). Sahin et al[60], in a series of pro-
phylactic NSM usually indicated the periareolar incision
for small-breasted patients. According to the authors,
the NSM and the reconstruction are performed through
this incision, extending circumareolar or semicircular in
the lower half of the NAC. Rivolin et al[35] in a series of
22 patients submitted to NSM evaluated the benets of
the periareolar approach associated with mastopexy for
patients with ptotic breasts. All patients in the periareo-
lar group were submitted to a one-stage reconstruction,
while a two-stage approach was selected in 20% of pa-
tients. The complication rate was higher in the periareolar
group, although the difference did not reach signicance.
Despite the satisfactory outcome, the mastopexy tech-
nique was inadequate if repositioning the NAC was more
than 3 cm or in sufciently large reductions to reduce ex-
cess skin. In women with larger and more ptotic breasts,
Chen et al[30] advocated the omega-type elliptical incision.
Similar to the periareolar incision with lateral extension,
the omega-type approach gave the surgeon wide access
to the breast regions and axilla.
Besides the limited exposure, the periareolar incision
485 August 10, 2014
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Figure 3 Nipple-sparing mastectomy/superior periareolar incision. A and B: A 52-year-old patient with in situ multifocal carcinoma in the right breast (4.8 cm) and
atypical hyperplasia in the left breast; C and D: The patient underwent a bilateral NSM mastectomy through a superior periareolar incision and sentinel lymph node
biopsy; E and F: The oncological procedure was immediately followed by a bilateral pedicled TRAM ap reconstruction. Four years postoperative appearance with a
very good outcome.
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
can result in an impairment to blood supply, which can
induce NAC necrosis. In fact, Regolo et al[19], in a series of
32 NSM utilizing the periareolar incision observed a high
rate of complications of the NAC (60%). Consequently,
Munhoz et al[21] developed an approach to improve the
surgical exposure based on total circumareolar incision.
This technique was based on the double concentric
periareolar incision to ressect the glandular tissue, while
maintaining the vascularization of the NAC through the
subdermal vascular plexus. In addition, the authors advo-
cated de-epithelializing the whole periareolar incision to
allow for triple-layer closure of the wound. Therefore, no
part of the suture lines present only one layer, thus less-
ening the risk of breast implant exposure.
The inframammary incision is the third most per-
formed approach for NSM. According to Endara et al[39]
the inframammary technique represents almost 20%
of all incisions performed for NSM. Blechman et al[34]
in a clinical series of 55 NSM through a lateral infra-
mammary incision performed in 29 consecutive patients
evaluated the technical aspects and outcome. The authors
indicated the lateral IMF approach for a variety of breast
volumes, and were able to place different volumes of im-
plants. According to the authors, the benets are related
to hiding the scar and the incision is the furthest from the
NAC and thus it is the least likely to threaten its vascular
stability. In addition, rotating the IMF incision laterally
facilitates easier access to the sentinel lymph node biopsy.
Contrarily, Chen et al[30] in their review of a series of 115
NSMs evaluated the risks and benets of the procedure
associated with immediate breast reconstruction. The
IMF approach was indicated for patients with smaller
486 August 10, 2014
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Figure 4 Nipple-sparing mastectomy/superior periareolar incision. A and B: A 56-year-old patient with invasive ductal carcinoma of the left breast (2.3 cm); C and D:
The patient underwent a left nipple-sparing mastectomy mastectomy with a superior periareolar incision and sentinel lymph node biopsy. The oncological procedure
was immediately followed by a free deep inferior epigastric perforator ap reconstruction; E and F: Five years postoperative appearance with a very good outcome.
The superior periareolar incision was converted to a total circumareolar incision in order to achieve a better symmetry during the second stage of reconstruction.
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
breasts. Stolier et al[20] observed that the inframammary
fold incision was uncertain. According to the authors,
surgical access to the recipient vessels may be prob-
lematic, making this incision more adequate to implant
reconstruction. In addition, they reported an inaccurate
dissection around the NAC and in the upper quadrants.
Similarly, Wijayanayagam et al[71] in a series of 64 NSMs
performed in 43 women observed that the inframamma-
ry incision provided a large exposure. However, they were
concerned about the ability to access the upper quadrants
in patients with large breasts and limited this incision to
patients with very small breasts. Thus, the authors recom-
mended using an incision of at least 10 cm because the
larger incision enables easier eversion of the skin for im-
proved visualization of sub-areolar region. Saliban et al[36]
analyzed 118 NSMs in 80 consecutive patients and ob-
served that patients with different breast sizes underwent
inframammary approach, except those patients who had
very large breasts or those who requested a breast lift.
Contrarily, some authors avoid the inframammary fold
incision due to the technical limitation to dissect the up-
per pole breast tissue and inadequate resection[20,30,33,36,60,70].
In fact, Chen et al[30] observed that although the infra-
mammary incision allows a better final position of the
scar, the resection of glandular tissue superiorly could be
more challenging. Additionally, in some cases the authors
believe that it is difcult to place the incision on the right
position once the nal implant volume is decided at the
end of the surgery[33]. Besides these limitations, some
authors believe that the inframammary incision could
impair the inframammary blood supply[36,72]. Proano and
Perbeck compared skin blood supply in patients having
either an inframammary approach or a lateral lazy S inci-
sion using laser Doppler and uorescein ometry[72]. In
a series of 69 patients, they observed a signicant reduc-
tion in ow to an area of skin 2 cm below the NAC in
the group submitted to inframammary approach.
The mammoplasty incision has been previously de-
scribed for planning SSM/NSM in ptotic breasts[1]. Clas-
sied by Carlson et al[5,6] as a Type IV, it involves breasts
that require a reduction of the skin ap and offers a wide
exposure[22,33,39,73-76]. According to Endara et al[39] the mam-
moplasty approach represents almost 4% of all incisions
performed for NSM. The main benefits are related to
a better surgical access in patients with large breast and
moderate/severe ptosis. Another potential advantage is
related to reduction of the skin envelope and the dead
space between the skin and the implant. Rusby observed
that a limited volume of fluid collecting between skin
flaps and reconstruction allows the preserved skin to
redrape over the breast mound to a variable and uncon-
trolled extent[75]. In fact, by reducing the skin ap, such
that it is closer to the breast mound size, movement is
Munhoz et al[33] reported that almost 35 percent of
the patients were submitted to the mammoplasty inci-
sion. The superior pedicle and inferior pedicle tech-
niques were indicated for moderate ptosis and severe
ptosis cases respectively. In spite of the main benefits,
this technique has some limitations since the lateral and
medial skin aps that close down to the inframammary
fold may become ischemic, and implant exposure can be
observed[33,74,75]. Another negative aspect is related to the
relative lack of space in the inferior and medial aspects
of the submuscular pocket. It is possible to release the
inferior aspect of the pectoralis muscle, however a sub-
cutaneous pocket could become an implant exposed, in
the situation of an ischemic NSM ap[22]. According to
Toth and Lappert[1], this aspect is critical and not rare if
the general surgeon during dissection needs to leave very
thin poorly vascularized NSM aps. Thus, the technique
requires close collaboration between the oncologic and
reconstructive surgeons. In higher risk patients or severe
breast ptosis, Munhoz et al[33] preferred the inferior pedicle technique since
the well-vascularized pedicle provides a stable soft-tissue
cover for the implant, which protects against exposure.
Similarly, Nava et al[22] in a series of 28 patients with ptotic
breasts proposed a combined flap technique to recon-
struct by use of anatomical silicone implants. After pre-
operative planning, a large area in the lower half of the
breast was deepithelialized according to the conventional
Wise pattern.
Skin ap and NAC complications
In spite of the NSM advantages, the outcome is not
always predictable. Surgical concerns are related to in-
creased complications such as wound healing problems
or ischemic necrosis[19,24-29,33]. In fact, one of the most
problematic complications of NSM is skin ap and NAC
necrosis, which can lead to unsatisfactory aesthetic result
(Table 3) (Figure 5).
Early reports on the NSM technique described high
rates of complications[18,28,30,57]. Gerber et al[57] in one of
the rst clinical series of NSM evaluated the NAC out-
come in 61 patients. The authors observed that 9.8% of
patients presented partial nipple necrosis with no cases
of total necrosis. Komorowski et al[28] observed a 7.9%in-
cidence of total nipple necrosis and a 5.3% of partial
nipple loss. In 2006, Sacchini et al[18] observed necrosis of
the nipple in 11% of the sample and it was judged mini-
mal in 59% of patients. Munhoz et al[33] identied patient
and breast related factors that increased complication
rates. Concerning the NAC outcome, the majority of
NAC demonstrated some degree of immediate ischemia
manifested by coolness. However, the NAC skin survived
in almost 95% of cases and partially survived in 4.4%. In
these cases, the NAC developed epidermolysis/partial-
thickness necrosis and most of these healed conserva-
Previous studies have reported some risk of skin
flap/NAC necrosis[20,24-30,33,36,39]. Although comparing
NAC necrosis rates between different populations, tech-
niques and experiences can be challenging, most studies
report rates from 0 to 19.5%[23,25]. As techniques have
improved, the rates of local complications have been re-
duced to satisfactory levels[19-22,24-27,33]. Some authors advo-
487 August 10, 2014
Volume 5
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Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
cate the use of lateral incisions, avoidance of periareolar
incisions which require more skin traction, limiting dis-
section beyond the lateral aspect of the anterior axillary
line and over the sternum to preserve blood supply to
the skin ap, and the use of scissors to avoid thermal le-
sion[11,44]. In addition, the option of the adequate surgical
approach is critical and depends on previous scars, tu-
mor location, breast volume, degree of ptosis and NAC
anatomy. Although large studies are necessary to evaluate
the best incision type, reduced NAC necrosis have been
described with radial areolar incisions[20,36,39,71,76].
In a recent review, Endara et al[39] evaluated the inci-
sion type and outcome following NSM. Based on 48
clinical studies in a pooled analysis, the authors reported
similar rates of NAC necrosis between radial and in-
framammary incisions (8.83% and 9.09%, respectively)
but an increased rate of necrosis following periareolar
approaches (17.81%). In this review, the transareolar
incision presented the highest incidence of nipple ne-
crosis (81.82%). Based on the results of this review, the
preferred incision is either the inframammary fold or the
radial with a lateral extension.
Contrarily, Munhoz et al[33] observed that the type of
incision was not signicantly predictive of complications
in univariate analysis. However, after adjusting for other
risk factors (BMI and weight of specimen), the prob-
ability of complications tends to be higher for hemi-
periareolar and Wise-pattern superior pedicle incision.
In addition, they observed a lower incidence of NAC
necrosis with the double circle incision technique. This
aspect is probably due to the full access along the inferior
border of NAC, which seems to allow adequate blood
supply to the NAC. The authors believed that besides
the limited access, the hemiperiareolar technique can
488 August 10, 2014
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Figure 5 Local complications following nipple-sparing mastectomy. A: Inferior periareolar incision with partial wound dehiscence; B: Superior periareolar incision
with partial nipple areola complex necrosis; C and D: Wise pattern incision with partial mastectomy and nipple areola complex necrosis; E and F: Inframammary inci-
sion with partial mastectomy necrosis.
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
potentially result in vascular impairment to blood supply
due to traction, which can induce partial necrosis. In fact,
Regolo et al[19] in a series utilizing the periareolar incision
observed a high rate of necrotic complication of the
NAC, which they abandoned in favor of a lateral incision.
Similarly, Stolier et al[20] reported no cases of nipple ne-
crosis when using a lateral or radial incision and Chung et
al[65] found adequate postoperative NAC viability by using
a periareolar and lateral skin incision or an inframammary
Some authors suggest that clinical co-morbidities are
relevant risk factors for complications[5,6,28,33,77-82]. Ko-
morowski et al[28] analyzed such factors and concluded
that age below 45 years is associated with a reduced risk
of necrosis. Contrarily, Munhoz et al[33] did not observe
age as a signicant factor for NAC necrosis. However, in
an univariate analysis the authors showed a signicantly
higher incidence of complications in the obese, hyperten-
sive and larger specimen group. In fact, the deleterious
effect of obesity on breast reconstruction was previously
studied[77,78,80]. One might suppose that increased BMI
may predispose the ap necrosis due to the compromised
sub-dermal plexus brought about by the increased sur-
face of the ap[83]. In addition, obese patients are likely to
have additional complications due to associated vascular
disease. Similarly as observed by Wooderman et al[79],
the authors observed that specimen weight more than
the mean weight seems to be associated with statistically
signicant odds ratios to develop complications[33]. This
aspect can be partially explained by a decreased perfusion
of the relatively large skin aps that result from SSM in
much larger breasts.
In general, the NSM reconstruction are related to autolo-
gous and alloplastic techniques and sometimes include
contra-lateral breast surgery. Various reconstructive tech-
niques have been described, and aesthetic outcomes of
NSM reconstruction continue to be met with variable
satisfaction rates. Choice of reconstructive technique re-
quires consideration of numerous patient related factors,
including: breast volume, degree of ptosis, areola size, pa-
tient preference and expectation, clinical factors, smoking
and surgeon experience. In addition, tumor related fac-
tors include size, location and proximity to the skin and
NAC. Regardless of the fact that there is no unanimity
regarding the best procedure, the criteria are determined
by the surgeon’s experience and the anatomical aspects
of the breast. The main advantages of the technique uti-
lized should include low interference with the oncological
treatment, reproducibility and long-term outcome.
During a NSM, the NAC is preserved and incisions
are located in more aesthetically regions. The breast vol-
ume, consisting of the breast tissue and fat, is entirely
removed and reconstruction of the breast skin is not nec-
essary. Thus, the objectives are to repair contour, volume
and position.
In a recent systematic review, Endara et al[39] examined
current trends with NSM, including the reconstructive
options. Based on 48 clinical studies that met the inclu-
sion criteria, yielding 6615 NSM, the authors observed
that 2373 (45.5 percent) were two-stage expander to
implant, 2126 (40.7 percent) were one-stage direct to im-
plant, and 719 (13.8 percent) were autologous tissue.
Autologous reconstructions involve pedicle flaps
such as the latissimus dorsi myocutaneous (LDMF) or
transverse rectus abdominis myocutaneous (TRAM)
aps. Although these techniques presents positive aspects
some limitations have arisen regarding the muscle resec-
tion[83-88]. Thus, alternatively free tissue transfer including
the deep inferior epigastric perforator (DIEP), pedicled
thoracodorsal perforator ap (TAP), free TRAM or the
gluteal artery perforator (GAP) flaps can be indicated
with a lower donor site morbidity. In fact, the DIEP ap
diverges from abdominal myocutaneous aps with main-
tenance of well-vascularized tissue and total abdominal
muscular and aponeurotic layer preservation[89-94]. Mo-
sahebi et al[83] in a series of 61 NSM reconstructions
compared alloplastic and autologous tissue in terms of
aesthetic outcome and satisfaction survey. According to
the authors, all three reconstruction methods (implant,
LDMF and DIEP) achieved good evaluation scores.
However, in patients who had adjuvant radiotherapy, to-
nometry demonstrated that the breast remained softer in
DIEP ap reconstruction.
In spite of the positive aspects, the outcome follow-
ing SSM and NSM reconstruction with autologous tissue
is not frequently predictable[39,95-97]. Utilizing autologous
tissue and particularly free aps require special consider-
ations in terms of recipient vessels and a monitoring skin
flap. Preoperatively the plastic surgeon should evaluate
the incision approach, the recipient vessels and the width
of the remaining skin flaps for adequate skin preserva-
tion. Munhoz et al[8] in a series of SSM DIEP reconstruc-
tions utilized ve different incision approaches. Accord-
ing to the authors, the criteria decision was based on the
breast anatomy (volume, ptosis and areola), the biopsy
incision and the tumor location. The periareolar inci-
sion was the second most common incision selected and
the restricted surgical exposure and difficulty in DIEP
489 August 10, 2014
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Table 3 Clinical outcome and vascular related complications
following nipple-sparing mastectomy
Ref. Year n Nipple necrosis
Total Partial
Petit et al[109] 2009 1001 35 55
Nahabedian et al[17] 2006 11 0 1
Spear et al[108] 2011 49 3 3
Voltura et al[50] 2008 51 0 0
De Alcantara Filho et al[23] 2011 341 0 1
Wijayanayagam et al[71] 2008 64 3 10
Jensen et al[27] 2011 127 0 8
Paepke et al[103] 2009 109 1 23
Babiera et al[107] 2010 54 0 4
Munhoz et al[33] 2013 158 1 8
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
anastomosis were the main negative technical aspects.
Thus, a correct selection of a suitable recipient pedicle is
decisive for a successful outcome[90,92-94]. In NSM, the use
of internal thoracic recipient vessels can be troublesome
since the surgical exposure is restricted[8,95]. Thus, longer
instruments and the use of endoscopic lighting are neces-
sary[95]. In this situation, some authors advocated the peri-
areolar approach with a lateral extension to obtain a bet-
ter exposure[94,95]. In addition, some authors advocate that use
of the internal thoracic vessels may result in a higher rate
of NAC necrosis compared with using the thoracodorsal
vessels[39,95]. Yang et al[95] in a series of 92 NSM free ap reconstructions utilized
the internal mammary vessels if the mastectomy ap did
not restrict the access. The authors observed that the
thoracodorsal vessels were indicated in 59 cases, and in-
ternal mammary vessels in 33 cases including 4 cases with
perforators of the internal thoracic vessels. In a selected
group of patients, the internal thoracic branches can be
used as an alternative to the internal mammary pedicle.
The main advantages are sparing the internal mammary
vessels and decreasing the operative time by limited dis-
section. However, Munhoz et al[92] reported that the inter-
nal thoracic branches are potentially available in only 55
percent of patients, therefore, this should not be the rst
option as recipient site.
Although autologous tissue presents advantages, it
is not adequate in all cases especially in those without
donor areas. In these cases, alloplastic techniques are usu-
ally indicated, and involve two-stage approach with tissue
expanders followed by silicone gel implant replacement
or one-stage reconstruction with conventional silicone
implants. Although NSM reconstruction can be per-
formed in a single stage, this is not the standard practice
in several cancer centers[39]. Enthusiasts of single-stage
reconstruction promote lower costs, however support-
ers of the two-stage approach advocate a second opera-
tion to improve symmetry and the unpredictability of
the NSM flaps. Chen et al[30] evaluated reconstruction
with tissue expander or silicone implant performed im-
mediately following the 115 NSM. Of the 66 patients, 58
patients underwent tissue expansion followed by subse-
quent implant placement in a two-stage reconstruction
(87.9 percent) and eight patients underwent one-stage
reconstruction (12.1 percent). The authors advocate that
with two-stage reconstruction, it is possible to achieve
the maximum control over the skin ap and by limiting
the volume of the tissue expander such that the skin en-
velope is not redundant, the risk of ischemia is reduced.
In addition, future aspects relating to NAC position,
asymmetry and implant asymmetry can be managed at
the time of the replacement of the tissue expander with
a silicone implant. Starting the reconstruction with a tis-
sue expander allows the reconstructive surgeon to cus-
tomize the results to patient preference. Endara et al[39]
has demonstrated that the incidence of NAC necrosis is
little increased with one-stage approach (4.50% x 3.90%),
however the overall complication rates were higher in the
two-stage group (52.4% x 18.6%). The authors empha-
sized that there is no ideal algorithm for reconstruction
and the decision to proceed with reconstruction and the
technique should be made by the surgeon based on as-
sessment of skin ap viability.
The introduction of biodimensional implant-expand-
er system (BIES) has proved increasingly popular over
the last years[9,21,33,97-102]. Designed with the objective of
combining the advantages of the silicone gel implant and
tissue expander into one system, it may present a superior
breast form compared with what might be achieved us-
ing unshaped implants or expanders. The system design
permits postoperative adjustments in implant volume and
contra-lateral symmetry[9,97-102].
In spite of the positive aspects, complications can be
expected and are best avoided by placing the BIES under
a submuscular pocket. Regardless of the good results ob-
served with total muscular coverage, in some patients this
technique is not free of unpredictable outcome[9,21,74,101,102].
Total muscular coverage can limit lower pole expansion
and can result in a high-riding device[74,102]. Mahdi et al[99]
in a series of BEIS reconstructions, observed that some
patients failed to develop adequate lower pole projec-
tion and 35 percent required inferior muscular release to
obtain a satisactory result. Munhoz et al[33] advocated per-
forming only minimal immediate expansion of the skin
aps in order to avoid tissue tension[29,33]. In fact, in a se-
ries of patients submitted to NSM reconstruction, Peled
et al[29] observed that NAC necrosis greatly decreased after
the technical refinements of incision selection and per-
forming implant reconstruction in a two-stage fashion.
Another option for implant coverage in NSM recon-
struction is the use of acellular dermal matrices (ADM).
Boneti et al[26 ] in a series of 281 NSM reconstructions
utilized the alloplastic tissue situated in a partial muscular
pocket, with ADM bridging the lateral and inferior edge
of the muscle and the chest wall. The authors observed
an overall complication rate of 7.1% (20 of 281) and the
most frequent complication was breast skin ap ischemia.
Spear et al[61] described a successful two staged NSM in
15 patients (24 breasts) utilizing the ADM. According to
the authors, four of the 24 operated breasts (17 percent)
experienced a complication, in that 2 patients (8 percent)
developed ap necrosis and two patients developed par-
tial NAC necrosis. Endara et al[39] in a systematic review
could not asses the impact of acellular dermal matrix
on reconstructive outcomes following NSM. According
to the authors, the studies either did not report acellular
dermal matrix use, or did indeed place acellular dermal
matrix for all cases in only three studies, totaling NSM
reconstructions. Given the insufficient number of pa-
tients comparison of complication rates between the two
groups was not possible.
NSM is not a new concept but is becoming increasingly
accepted by breast surgeons. In selected patients, this
approach has allowed an adequate oncologic control with
490 August 10, 2014
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Munhoz AM
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. Immediate nipple-areola-sparing mastectomy reconstruction
satisfactory aesthetic outcome. Although NSM requires
more intraoperative care, the concept can optimize the
aesthetic result in early-stage breast cancer patients.
The satisfactory outcome are due to a close col-
laboration with the oncological surgical team in terms
of incision selection flexibility and skin flap dissection.
Alternately, care must be taken during the oncological
procedure with meticulous surgical technique and gentle
handling of tissues to avoid complications. In general,
choice of reconstructive procedure requires careful
consideration of various patient related factors, includ-
ing: breast volume, degree of ptosis, areolar size, patient
preference and expectation, clinical factors, and surgeon
experience. Regardless of the fact that there is no con-
sensus concerning the best technique, the criteria are de-
termined by the surgeon’s experience and the anatomical
aspects of the breast. Probably, all these objectives are
not achieved by any single procedure and each technique
has advantages and limitations. With careful patient selec-
tion and well-planned surgical technique, NSM can pro-
vide satisfactory outcomes with acceptable complication
rates. However, available data demonstrate that NSM can
be safely performed for breast cancer treatment in se-
lected cases. Additional studies and longer follow-up are
necessary to dene consistent selection criteria for NSM.
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P- Reviewer: Heo CY, Jun Y S- Editor: Ji FF L- Editor: A
E- Editor: Lu YJ
494 August 10, 2014
Volume 5
Issue 3
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
... Breast reconstruction following mastectomy continues to be a valuable element of breast cancer treatment and plastic surgery practice [6,7]. Among the main reconstructive procedures, expander/implant remains more prevailing than autologous reconstruction, accounting for nearly 70% of all procedures [8][9][10]. ...
... Due to quality-of-life issues and benefits, immediate breast reconstruction (performed at the time of mastectomy) has steadily increased during the past two decades [6,7,11]. While only 15% of women who underwent mastectomy had immediate reconstruction in 2011, this number increased to about 40% in 2018 [11][12][13]. ...
... Concerning the reconstruction technique, the option of a tissue expander is determined by the patient's anatomy and surgeon-related issues and availability. Factors related to the patient, such as anatomy, BMI, breast volume and ptosis, and quality of the oncological surgery may influence the plastic surgeon's option for the reconstructive procedure and also the risk of postoperative complications [6,7]. In our series, the overall incidence of late complications was 4.4%, with the predominance of severe capsular contracture (8/11), as observed in other publications [34]. ...
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Background and purpose: Breast reconstruction following mastectomy is a relevant element of breast cancer treatment. The purpose of this study was to evaluate the influence of radiotherapy (RT) on local complications in patients with breast cancer that had undergone breast reconstruction with alloplastic material. Materials and methods: Retrospective study of breast cancer patients submitted to mastectomy and breast reconstruction from 2009 to 2013. Clinical and treatment variables were correlated with early and late complications. Results: 251 patients were included; mean age was 49.7 (25 to 78) years. Reconstruction was immediate in 94% of the patients, with 88% performed with a temporary tissue expander. Postoperative radiotherapy (RT) was delivered to 167 patients (66.5%). Early complications were present in 26.3% of the patients. Irradiated patients presented 5.4% incidence of late complications versus 2.4% for non-irradiated patients (p = 0.327). Diabetes (OR = 3.41 95% CI: 1.23-9.45, p = 0.018) and high body mass index (BMI) (OR = 2.65; 95% CI: 1.60-4.37, p < 0.0001) were the main risk factors. The overall incidence of late complications was 4.4%, with predominance of severe capsular contracture (8/11). Arterial hypertension (OR = 4.78; 95% CI: 1.97-11.63, p = 0.001), BMI (OR = 0.170; 95% CI: 0.048-0.607, p = 0.006) and implant placement (OR = 3.55; 95% CI: 1.26-9.99, p = 0.016) were related to late complications. Conclusions: The overall rate of complications was low in this population. Radiotherapy delivery translated into a higher but not statistically significant risk of late complications when compared with the non-irradiated patients. Already well-known clinical risk factors for complications after breast reconstruction were identified.
... Одномоментная реконструкция с установкой имплантата также является хорошим вариантом для нормостеничных пациенток с небольшим количеством аутологичных донорских участков ткани, пациенток, занимающиеся спортом, которые не хотят ставить под угрозу физическую функцию в других областях тела в результате забора лоскута, а также пациенток с сопутствующими заболеваниями, у которых нежелательно увеличение продолжительности общей анестезии. Кроме того, при данном виде реконструкции требуется только 1 хирургическое вмешательство, что сокращает общую продолжительность операции, анестезии и период пребывания пациентки в стационаре, что, в свою очередь, делает этот вид реконструкции не только более удобным для пациенток, но и экономически выгодным для системы здравоохранения, и это частично объясняет увеличивающееся количество выполняемых одномоментных реконструкций имплантатами [19][20][21][22]. ...
The evolution in reconstructive breast surgery in the form of widespread use of implants allows you to abandon the “simple” mastectomy in most patients, provide faster rehabilitation and minimize the psychological trauma due to the absence of a breast. However, in most cases, radiation therapy and/or drug treatment are necessary, as they reduce the risk of relapse, disease progression and mortality. The combined or complex treatment increases the frequency of postoperative complications, such as prolonged wound healing, infection, protrusion/extrusion of the endoprosthesis, the development of capsular contracture, seroma, hematoma, etc. The greatest negative impact on the aesthetic result, both in the early and in the long-term period, is provided by remote radiation therapy. On the other hand, performing reconstructive plastic surgery may complicate radiation therapy. The issues of how long it is necessary to conduct radiation therapy, what type of reconstruction and how to conduct radiation therapy, how to minimize the frequency of complications without compromising the oncological and aesthetic results of treatment of breast cancer patients remain controversial.
... In the absence of contraindications and with the patient's consent, either a nipple-sparing (NSM) or skin sparing mastectomy (SSM) of the affected breast should be performed. Immediate breast reconstruction yields a high patient satisfaction rate and its use in surgical cancer therapy is steadily increasing (2)(3)(4)(5). In surgical breast reconstruction, the pectoralis major muscle is the essential muscle for the formation of an implant pocket, but its dimension is shortened by subpectoral implant insertion, making the use of synthetic mesh or ADM essential (6). ...
Aim: This research compares postoperative complication rates with Strattice™, SERAGYN® BR, and TiLOOP® Bra interposition devices for subpectoral implant placement after skin or nipple sparing mastectomy. Patients and methods: 188 breast reconstructions in 157 patients after primary (n=96), secondary (n=71), or prophylactic (n=21) surgery were analyzed regarding major and minor complications. Results: With acellular dermal matrix (ADM) Strattice™, 27.5% major and 27.5% minor complications occurred. Implant loss rates were 27.3% in primary and 30.8% in secondary reconstructions. With SERAGYN® BR, 11.1% major and 13,0% minor complications occurred. Implant losses (6.1%) occurred exclusively in primary reconstructions. With TiLOOP® Bra, 14.9% major and 9.6% minor complications occurred. Implant loss rates were 7.7% in primary and 7.1% in secondary reconstructions. Conclusion: ADM was associated with high complication rates in primary and secondary reconstructions. Low complication rates were seen with mesh interposition devices in primary, secondary, and prophylactic reconstructions.
... Several types of surgical incisions are used in NSM, such as radial, periareolar, transareolar, Wise pattern, and inframammaryfold incisions. 17,24 Although an incision on the inframammary fold may offer a lower risk of NAC necrosis than periareolar incision, 16,17,25 the periareolar incision is both convenient during the operation 26,27 and accessible after removal of the skin involved. The distribution of NAC perfusion found in our study suggests that the periareolar incision should be designed along the inferior border of the areola. ...
Background Understanding the main blood supply to the nipple-areola complex (NAC) is important for breast plastic surgery. However, previous reports have involved studies of cadavers and small sample sizes. Objectives This study aimed to identify and classify the in vivo blood supply to the NAC based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Methods DCE-MRI images of 393 breasts in 245 Asian women obtained from March 2012 to October 2019 were included retrospectively. Axial, coronal, and sagittal maximum-intensity projection images were evaluated to identify all vessels supplying the NAC. Blood supply to the NAC was classified into 9 anatomic zones: superomedial (Ia), medial (Ib), inferomedial (Ic), superolateral (IIa), lateral (IIb), inferolateral (IIc), central (III), inferior (IV), and superior (V). Results A total of 637 source vessels were identified in 393 breasts. Of the 393 breasts, 211 (53.7%) were supplied by a single zone, 132 (33.6%) by 2 zones, 38 (9.7%) by 3 zones, and 12 (3.1%) by 4 zones. Of the 637 vessels, 269 (42.2%) vessels were in zone Ia, 180 (28.3%) vessels were in zone IIa, and <10% of vessels were in the other zones. The number of NAC perfusion zones (P = 0.093) and the distribution of source vessels (P = 0.602) did not differ significantly between the left and right breasts. Conclusions DCE-MRI provides a clear indication of the blood supply to the NAC. Blood vessels from the superomedial and superolateral zones were the predominant sources of blood supplying the NAC.
... Nipple-areolar preservation in the ptotic population is another domain receiving increased emphasis. To improve cosmesis in grade II and III ptosis, staged techniques for nipple-sparing mastectomy have been described by several authors (56)(57)(58). In 2012, Spear described a threestage approach to spare the NAC in which women first underwent an oncoplastic mastopexy/reduction, followed by a completion mastectomy through the mastopexy incisions, and then the final reconstruction with a prosthesis (59). ...
Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "high-risk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.
Nipple-sparing mastectomy (NSM) has increasingly been employed as a procedure that provides an excellent cosmetic benefit. However, it generally presupposes breast reconstruction. Herein, we report four patients with breast cancer who underwent NSM with omission of primary breast reconstruction between August 2008 and November 2010. Their mean age was 52 years, and their mammograms revealed calcification and extensive foci. A peri-areolar with lateral extension incision was performed in all the patients, whereas intraoperative frozen section diagnosis of the surgical margin on the nipple side was performed in three patients. The final pathological diagnosis was invasive ductal carcinoma in two patients and ductal carcinoma in situ (DCIS) in the other two patients. The margin on the nipple side of two of the four patients were also found to be histologically positive. Postoperative complications, including nipple necrosis and infection, were not observed. The postoperative level of satisfaction was high in all the patients, since they did not feel a sense of breast loss. There was one case of nipple recurrence during a follow-up period of ≥10 years, which resolved with local resection without relapse. Therefore, NSM without primary breast reconstruction can be a treatment option for selected cases, including extensive DCIS.
Background Skin/nipple-sparing mastectomies (SSM/NSSM) have been reported to have acceptable complication rates and good aesthetic outcomes with high patient satisfaction. However, in this relatively young and rapidly expanding field of reconstructive plastic surgery, differences in perioperative management are noted between breast centers. Prospective studies of complication rates using a titanized polypropylene mesh (TiLOOP® Bra) are currently lacking. Methods A prospective subgroup analysis was performed based on the data set of the prospective, single-arm, multicenter observational study (PRO-BRA). Early complication rates after skin/nipple-sparing mastectomy with implant-based immediate or secondary reconstruction using a titanized polypropylene mesh (TiLOOP® Bra) subpectorally were investigated in relation to demographic factors, as well as intra-and postoperative management. The subgroup consists of 258 patients. Complications were categorised into necrosis, infection, postoperative bleeding or hematoma, seroma, wound healing delays and R1-situations. Results Early complication rates of SSM/NSSM using titanium-based meshes are comparable to complication-rates using ADM's. Logistic regression shows significantly higher risk for wound healing delays, necrosis and seroma with increasing BMI, abladat- and implant-weight (OR 1,17 -1,66, p-value < 0,001). Smokers have significantly higher necrosis rates (20.7%) compared to non-smokers (5.5%) (p-value = 0.002). Discharge with drainage results in a trend toward higher rates of wound healing complications. Conclusion The use of TiLOOP® Bra meshes was shown to have acceptable complication rates. Complication rates depend mainly on certain demographic factors and should be considered in indications and information of patients.
Breasts symbolise femininity, sexuality and motherhood. The breast size and shape affect the woman’s self-esteem and social activity. Surgical treatment of malignant breast diseases concerns the medical, psychological, social and sexual aspects of life. Surgery for breast cancer dawns back to 1,600 B.C., with a milestone operation of radical mastectomy proposed in 1891–1894 by W. Halsted and W. Meyer and modified by D. Patey and W. Dyson in 1948. Tissue preservation has shaped a trend towards improving the technique. Since the 1990s, the modified J. Madden’s operation has become the treatment standard in breast cancer, irregardless of stage. The improvement of mass first-visit check-up advanced early diagnosis of initial breast tumourisation, which also influenced the choice of surgical tactics. U. Veronesi proposed a variant of organ-preserving surgery in 1970–80s involving three-level axillary lymph node dissection quadrantectomy, followed by radiotherapy. This combination facilitated aesthetic results at no compromise of radicality of the treatment. The need to observe radicality and sustain aesthetics contributed to the integration of plastic surgery into oncological cure and emergence of reconstructive and plastic breast surgery. The field has entered new cycle. Oncoplastic surgery is recognised safe, improves aesthetics and gives a salutary impact on psychological and social adjustment. Manifold surgical options in breast cancer coexist and develop towards maximal tissue preservation.
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Background SmoothSilk implants (SSI) are the first generation of implants to incorporate a radio-frequency identification device (RFID-M), a non-invasive traceability system. Although the RFID-M is considered compatible with magnetic resonance imaging (MRI), the size of the artifact and its influence on breast tissue vary. This prospective study assessed safety and MRI issues in a cohort of breast reconstruction patients.Methods Forty-four SSI were used for breast reconstruction in patients undergoing treatment for breast cancer. All patients were evaluated for magnetic field interactions, MRI-related heating and artifacts in a 1.5-T MRI unit using standard T1/T2-weighted sequences utilized in clinical assessment of breast tissue/implants.ResultsMean patient age was 41.5 years (27–53ys) and body mass index was 28+-6.44 kg/m2. In 18/22 patients (81.8%), mastectomies were unilateral. No patients reported local heat/discomfort. All implants showed RFID-M-related artifacts with an estimated mean volume in T1 of 42.9cm3 (26.2–63.6cm3; SD±8.6 and 95% CI, 40.37–45.45) and in T2 of 60.5cm3 (35.4–97.2cm3; SD±14.7 and 95% CI, 56.29–65.01). Artifact volume was smaller in T1 than in T2, to a statistically significant degree (p <0.001). There were no statistically significant differences in artifact volume according to surgical indication, breast side or implant volume. There were 4/44 (9%) cases of minor rotation (<45°). In all cases, adequate analysis of the breast tissue was performed.Conclusions The results demonstrate that SSI with RFID-M technology presented an artifact volume of 42.9cm3 and 60.5cm3 in T1 and T2 images, respectively. Our findings provide detailed information on the quality and location of MRI artifacts in a reconstructed cohort which can help guide clinical decision-making for patients. To our knowledge, this is the first time RFID-M breast implants have been prospectively evaluated for clinical and MRI issues in a cohort of reconstructive patients.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors
Introduction Spira technique is a type of nipple-sparing mastectomy that allows immediate reconstruction (IBR), ideal for ptotic breasts. Although, controversy persists regarding oncological results in breast cancer. The aim is to analyze complications, cosmetic outcomes, causes of reoperation and oncological results. Methods Retrospective observational analysis of patients undergone surgery during 2003–2018 in our center. Study population is based on patients with breast carcinoma or undergoing prophylactic mastectomy due to high-risk, in which a skin-sparing mastectomy with a de-epithelialized derma-fat flap (modified Spira technique) and direct to implant reconstruction was performed. Short and long-term complications, sequelae, tumor recurrence and survival rates are analyzed. Results A total of 247 mastectomies with immediate reconstruction in 139 patients, 216 bilateral (87.4%) and 31 unilateral (12.5%) were performed. 121 therapeutic (49%) and 126 prophylactic (51%). Median follow-up 81 months. Complications were observed in 16.2%; skin necrosis 5.3% and 5 cases of NAC necrosis (2%). Reoperation rate due to cosmetic sequelae was 17.4% (capsular contracture was the most frequent,11.3%) and a 39.3% of these patients have received RT. Recurrence of 14% (0.8% skin, 3.3% locoregional and 9.9% metastatic), 8 patients died (6.6%). Rates of FSD and OS were 92.6% and 93.3% respectively. Conclusion Spira mastectomy is a safe option and provides good cosmetic and oncologic results as breast cancer treatment and prophylaxis in moderate-large ptotic breasts.
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The role of nipple-sparing mastectomy (NSM) for breast cancer is controversial as there is concern regarding its oncological safety and complication rate. We carried out a review of the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates and quantify NSM complication rates.
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Nipple-sparing mastectomy (NSM) is increasingly offered to women for therapeutic and prophylactic indications. Although, clinical series have been described, there are few studies describing risk factors for complications. The objective of this study is to evaluate the incidence of complications in a series of consecutive patients submitted to NSM and differences between clinical risk factors, breast volume, and different incision types. In a cohort-designed study, 158 reconstructed patients (invasive/in situ cancer and high risk for cancer) were stratified into groups based on different types of incision used (hemi-periareolar, double-circle periareolar, and Wise-pattern). They were matched for age, body mass index, associated clinical diseases, smoking, and weight of specimen. Also included were patients treated with adjuvant chemotherapy and postoperative radiotherapy. Mean follow-up was 65.6 months. In 106 (67 %) patients, NSM was performed for breast cancer treatment and in 52 (32.9 %) for cancer prophylaxis. Thirty-nine (24.6 %) patients were submitted to hemi-periareolar technique, 67 (42.4 %) to double-circle periareolar incision, and 52 (33 %) to Wise-pattern incision. The reconstruction was performed with tissue expander and implant-expander. Local recurrence rate was 3.7 % and the incidence of distant metastases was 1.8 %. Obese patients and higher weight of specimen had a higher risk for complications. After adjusting risk factors (BMI, weight of specimen), the complications were higher for patients submitted to hemi-periareolar and Wise-pattern incisions. This follow-up survey demonstrates that NSM facilitates optimal breast reconstruction by preserving the majority of the breast skin. Selected patients can have safe outcomes and therefore this may be a feasible option for breast cancer management. Success depends on coordinated planning with the oncologic surgeon and careful preoperative and intraoperative management. Surgical risk factors include incision type, obesity, and weight of breast specimen.
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: The role of nipple-sparing mastectomy for breast cancer is controversial, as there is concern regarding its oncologic safety and complication rate. The authors reviewed the literature to quantify the incidence of occult nipple malignancy in breast cancer, identify the factors influencing occult nipple malignancy, quantify locoregional recurrence rates, and quantify nipple-sparing mastectomy complication rates. : A search of the literature was performed using PubMed. Key words used were "mastectomy," "nipple involvement," "nipple-sparing mastectomy," "skin-sparing mastectomy," "occult nipple malignancy," "occult nipple disease," and "breast cancer recurrence." Articles were analyzed regarding incidence of occult nipple malignancy, potential factors influencing the incidence of occult malignancy, and recurrence/complications following nipple-sparing mastectomy. The incidence of occult nipple disease was compared between groups using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. Values of p < 0.05 were considered significant. : The overall rate of occult nipple malignancy was 11.5 percent. Primary tumor characteristics influencing occult nipple malignancy were tumor-nipple distance less than 2 cm, grade, lymph node metastasis, lymphovascular invasion, human epidermal growth factor receptor-2-positive, estrogen receptor/progesterone receptor-negative, tumor size greater than 5 cm, retroareolar/central location, and multicentric tumors. The overall nipple recurrence rate considered significant was 0.9 percent, and the skin flap recurrence rate was 4.2 percent. Full- and partial-thickness nipple necrosis rates were 2.9 and 6.3 percent, respectively. : Nipple-sparing mastectomy for primary breast cancer is appropriate in carefully selected patients. All patients should have retroareolar sampling. There is strong evidence to suggest that suitable cases are well circumscribed single or multifocal lesions that have a tumor-to-nipple distance greater than 2 cm. Tumors should be grade 1 to 2 and not have lymphovascular invasion, axillary node metastasis, or human epidermal growth factor receptor-2 positivity.
The purpose of this article is to determine whether or not the transverse rectus abdominis musculocutaneous (TRAM) flap procedure is a practical operation for immediate breast reconstruction. Our series reports 128 consecutive patients who underwent immediate breast reconstruction with the TRAM flap from 1985 to 1990. Of these patients, 86 underwent conventional TRAM, while 40 underwent free TRAM breast reconstruction. Two-thirds of the patients underwent bilateral breast reconstruction. Comparison within this series of the free TRAM versus the conventional TRAM flap revealed improved statistics with regard to the free TRAM flap in a shorter hospitalization time and a decreased incidence of fat necrosis. There is no evidence to date that there is an increased chance of local recurrence with immediate breast reconstruction in this series, and chemotherapy was delayed in a single patient because of healing problems after immediate reconstruction. Operative times and the complication rate seem to be improving as compared with other series previously reported. The TRAM procedure, particularly the free TRAM procedure, is a primary choice for immediate breast reconstruction after mastectomy. (C)1993American Society of Plastic Surgeons
Different approaches have been advocated for performing nipple-areola-sparing mastectomy. The inframammary approach has been viewed as having limited applications, particularly in large breasts. The authors review their experience with nipple-areola-sparing mastectomy using the inframammary approach for different breast sizes. Between 2005 and 2012, 118 nipple-areola-sparing mastectomies with staged implant-based reconstruction were performed in 80 consecutive patients. Patients with different breast sizes underwent inframammary nipple-areola-sparing mastectomy, except those patients who had very large breasts or those who requested a breast lift. Oncologic data related to tumor size, selection criteria, and recurrences are presented. All nipple-areola-sparing mastectomies and reconstructions were performed by the same surgeons (J.K.H. and A.H.S), who operated as a team in performing the mastectomies. Patients were followed up from 6 to 97 months (mean, 33.5 months). There were four recurrences (5 percent), three of which were attributed to the biological behavior of the tumor. The aesthetic outcomes of the reconstructions were analyzed based on nipple location, breast contour, and symmetry: 35 patients (44 percent) had a very good result, 28 (35 percent) had a good result, nine (11 percent) had a fair result, and eight (10 percent) had a poor result. Risk factors and complications affecting the final aesthetic outcome are discussed. The inframammary approach for nipple-areola-sparing mastectomy is the authors' procedure of choice for small, medium, and large breasts. The team approach to the mastectomy facilitates the procedure, reduces skin-related complications, and results in a better aesthetic outcome. Therapeutic, IV.
Nipple sparing mastectomy (NSM) is a controversial option for the treatment of breast cancer based upon concern for local regional recurrence and distant metastasis. In addition to these oncologic factors, there are technical factors such as ideal incision type or reconstructive options that are also debatable. This systematic review examines current trends with NSM that includes selection criteria, local-regional and distant metastasis rates, incision choice, and reconstructive options. Systematic electronic searches were performed in the Pubmed and Ovid databases using search terms for studies reporting outcomes following NSM and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed. A total of 48 studies met inclusion criteria for review yielding 6,615 NSMs for analysis. The overall pooled complication rate was 22%, nipple necrosis rate was 7%, local regional recurrence rate was 1.8%, and distant metastasis rate was 2.2%. Comparing combined patient cohorts for two stage expander to implant, one stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8%, 16.7% and 23.7% and nipple necrosis rate of 4.5%, 4.1% and 17.3% respectively. The various incision types were combined into five categories: radial, periareolar/circumareolar, inframammary, mastopexy and transareaolar with nipple necrosis rates of 8.83%, 17.81%, 9.09%, 4.76% and 81.82% respectively CONCLUSIONS:: Nipple sparing mastectomy appears to be an oncologically safe option for properly selected patients with low rates of local regional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method chosen. Randomized controlled trials are warranted to determine best incision and reconstructive method. Therapeutic 2.