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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,
Brazil. munhozalex@uol.com.br
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
Abstract
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 inuencing 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-
TOPIC HIGHLIGHT
Immediate nipple-areola-sparing mastectomy
reconstruction: An update on oncological and reconstruction
techniques
WJCO 20th Anniversary Special Issues (2): Breast Cancer
Submit a Manuscript: http://www.wjgnet.com/esps/
Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx
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
W
J C O
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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 dene consistent selection criteria for
NSM.
© 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].
LITERATURE SEARCH/DATA
EXTRACTION
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-
tied 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-
tied 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 identied 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
review.
ONCOLOGICAL ASPECTS
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
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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.
wjgnet.com/2218-4333/full/v5/i3/478.htm DOI: http://dx.doi.
org/10.5306/wjco.v5.i3.478
INTRODUCTION
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 chiey 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 magnied[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 dene signicant 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 signicant 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
Ⅲ 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 inltration, 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
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Table 1 Occult neoplastic involvement of the nipple areola complex
Ref. Year
n
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 benet 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
follow-up.
In a recent review, Mallon et al[59] quantied 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 denitive 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
claried, 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
identied on frozen sections of the subareolar tissue or
denitive 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
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Table 2 Clinical outcome and local recurrences following nipple-sparing mastectomy
Ref. Year
n
Stage Follow-up (mo) Nipple areola complex recurrence Local recurrence
Gerber et al[25] 2009 61 0-Ⅰ 59 1.6 5.4
Garcia-Etienne et al[15] 2006 42 0-Ⅰ 10.5 0 0
Bistoni et al[106] 2006 10 0-Ⅰ 36 0 0
Voltura et al[50] 2008 51 0-Ⅲ 18 0 5.9
Crowe et al[14] 2004 54 0-Ⅱ 41 0 0
Petit et al[104] 2005 579 0-I 19 0 0.9
Sacchini et al[18] 2006 192 0-Ⅲ 24.6 0 3
Paepke et al[103] 2009 109 0-Ⅲ 34 0 1.83
Babiera et al[107] 2010 54 0-Ⅲ 15 0 0
Benediktsson et al[105] 2008 216 0-Ⅲ156 0 8.5
Munhoz et al[33] 2013 158 0-Ⅱ 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 denitive 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 rene the breast contour such as by fat graft-
ing.
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 signicantly 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
approaches.
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 denitive 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 signicantly 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
satisfactory.
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 difculties, 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 congura-
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
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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.
A B D E
F G H I
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 prole 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
benets are related to scar camouage with a more sat-
isfactory outcome. Despite its advantages, the periareo-
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A B
C D
E F
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 difculty 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 benets 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 signicance.
Despite the satisfactory outcome, the mastopexy tech-
nique was inadequate if repositioning the NAC was more
than 3 cm or in sufciently 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
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A B
C D
E F
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 benets 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 benets of the procedure
associated with immediate breast reconstruction. The
IMF approach was indicated for patients with smaller
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A B
C D
E F
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 difcult 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 signicant 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-
sied 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
reduced.
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] identied 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-
tively.
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-
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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 signicantly 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
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A B
C D
E F
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
approach.
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 signicant factor for NAC necrosis. However, in
an univariate analysis the authors showed a signicantly
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
signicant 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.
RECONSTRUCTIVE ASPECTS
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
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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.
CONCLUSION
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
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Munhoz AM
et al
. 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 dene consistent selection criteria for NSM.
REFERENCES
1 Toth BA, Lappert P. Modified skin incisions for mastec-
tomy: the need for plastic surgical input in preoperative
planning. Plast Reconstr Surg 1991; 87: 1048-1053 [PMID:
1852020]
2 Kroll SS, Ames F, Singletary SE, Schusterman MA. The
oncologic risks of skin preservation at mastectomy when
combined with immediate reconstruction of the breast. Surg
Gynecol Obstet 1991; 172: 17-20 [PMID: 1985335]
3 Singletary SE. Skin-sparing mastectomy with immediate
breast reconstruction: the M. D. Anderson Cancer Center
experience. Ann Surg Oncol 1996; 3: 411-416 [PMID: 8790856]
4 Simmons RM, Adamovich TL. Skin-sparing mastectomy.
Surg Clin North Am 2003; 83: 885-899 [PMID: 12875600]
5 Carlson GW, Bostwick J, Styblo TM, Moore B, Bried JT,
Murray DR, Wood WC. Skin-sparing mastectomy. Onco-
logic and reconstructive considerations. Ann Surg 1997; 225:
570-55; discussion 570-55; [PMID: 9193184]
6 Carlson GW. Skin sparing mastectomy: anatomic and
technical considerations. Am Surg 1996; 62: 151-155 [PMID:
8554192]
7 Slavin SA, Schnitt SJ, Duda RB, Houlihan MJ, Koufman
CN, Morris DJ, Troyan SL, Goldwyn RM. Skin-sparing mas-
tectomy and immediate reconstruction: oncologic risks and
aesthetic results in patients with early-stage breast cancer.
Plast Reconstr Surg 1998; 102: 49-62 [PMID: 9655407]
8 Munhoz AM, Arruda E, Montag E, Aldrighi C, Aldrighi JM,
Gemperli R, Ferreira MC. Immediate skin-sparing mastec-
tomy reconstruction with deep inferior epigastric perforator
(DIEP) ap. Technical aspects and outcome. Breast J 2007;
13: 470-478 [PMID: 17760668]
9 Munhoz AM, Aldrighi C, Montag E, Arruda EG, Aldrighi
JM, Filassi JR, Ferreira MC. Periareolar skin-sparing mas-
tectomy and latissimus dorsi ap with biodimensional ex-
pander implant reconstruction: surgical planning, outcome,
and complications. Plast Reconstr Surg 2007; 119: 1637-149;
discussion 1637-149; [PMID: 17440335]
10 FREEMAN BS. Subcutaneous mastectomy for benign breast
lesions with immediate or delayed prosthetic replacement.
Plast Reconstr Surg Transplant Bull 1962; 30: 676-682 [PMID:
13959443]
11 Garcia-Etienne CA, Cody Iii HS, Disa JJ, Cordeiro P, Sac-
chini V. Nipple-sparing mastectomy: initial experience at
the Memorial Sloan-Kettering Cancer Center and a compre-
hensive review of literature. Breast J 2009; 15: 440-449 [PMID:
19496781 DOI: 10.1111/j.1524-4741.2009.00758.x.]
12 Cense HA, Rutgers EJ, Lopes Cardozo M, Van Lanschot JJ.
Nipple-sparing mastectomy in breast cancer: a viable op-
tion? Eur J Surg Oncol 2001; 27: 521-526 [PMID: 11520082]
13 Stanec Z, Zic R, Stanec S, Budi S, Hudson D, Skoll P. Skin-
sparing mastectomy with nipple-areola conservation. Plast
Reconstr Surg 2003; 111: 496-48; author reply 498 [PMID:
12496632]
14 Crowe JP, Kim JA, Yetman R, Banbury J, Patrick RJ, Baynes
D. Nipple-sparing mastectomy: technique and results of 54
procedures. Arch Surg 2004; 139: 148-150 [PMID: 14769571]
15 Garcia-Etienne CA, Borgen PI. Update on the indications
for nipple-sparing mastectomy. J Support Oncol 2006; 4:
225-230 [PMID: 16724644]
16 Caruso F, Ferrara M, Castiglione G, Trombetta G, De Meo L,
Catanuto G, Carillio G. Nipple sparing subcutaneous mas-
tectomy: sixty-six months follow-up. Eur J Surg Oncol 2006;
32: 937-940 [PMID: 16829015]
17 Nahabedian MY, Ts angaris TN. Br ea st reconstructi on
following subcutaneous mastectomy for cancer: a critical
appraisal of the nipple-areola complex. Plast Reconstr Surg
2006; 117: 1083-1090 [PMID: 16582769]
18 Sacchini V, Pinotti JA, Barros AC, Luini A, Pluchinotta A,
Pinotti M, Boratto MG, Ricci MD, Ruiz CA, Nisida AC, Ve-
ronesi P, Petit J, Arnone P, Bassi F, Disa JJ, Garcia-Etienne
CA, Borgen PI. Nipple-sparing mastectomy for breast can-
cer and risk reduction: oncologic or technical problem? J Am
Coll Surg 2006; 203: 704-714 [PMID: 17084333]
19 Regolo L, Ballardini B, Gallarotti E, Scoccia E, Zanini V.
Nipple sparing mastectomy: an innovative skin incision
for an alternative approach. Breast 2008; 17: 8-11 [PMID:
17870535]
20 Stolier AJ, Sullivan SK, Dellacroce FJ. Technical consider-
ations in nipple-sparing mastectomy: 82 consecutive cases
without necrosis. Ann Surg Oncol 2008; 15: 1341-1347 [PMID:
18256883 DOI: 10.1245/s10434-007-9753-5]
21 Munhoz AM, Aldrighi C, Montag E, Arruda E, Aldrighi
JM, Filassi JR, Ricci M, Brasil JA, Rezende V, Ferreira MC.
Optimizin g the nipple -ar eola sparing mastectomy with
double concentric periareolar incision and biodimensional
expander-implant reconstruction: aesthetic and technical
renements. Breast 2009; 18: 356-367 [PMID: 19944335 DOI:
10.1016/j.breast.2009.09.008]
22 Nava MB, Cortinovis U, Ottolenghi J, Riggio E, Pennati A,
Catanuto G, Greco M, Rovere GQ. Skin-reducing mastec-
tomy. Plast Reconstr Surg 2006; 118: 603-10; discussion 611-3
[PMID: 16932166]
23 de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pu-
sic A, Sacchini VS. Nipple-sparing mastectomy for breast
cancer and risk-reducing surgery: the Memorial Sloan-
Kettering Cancer Center experience. Ann Surg Oncol 2011;
18: 3117-3122 [PMID: 21847697 DOI: 10.1245/s10434-011-
1974-y]
24 Tokin C, Weiss A, Wang-Rodriguez J, Blair SL. Oncologic
safety of skin-sparing and nipple-sparing mastectomy: a
discussion and review of the literature. Int J Surg Oncol 2012;
2012: 921821 [PMID: 22848803 DOI: 10.1155/2012/921821]
25 Gerber B, Krause A, Dieterich M, Kundt G, Reimer T.
The oncological safety of skin sparing mastectomy with
conservation of the nipple-areola complex and autolo-
gous reconstruction: an extended follow-up study. Ann
Surg 2009; 249: 461-468 [PMID: 19247035 DOI: 10.1097/
491 August 10, 2014
|
Volume 5
|
Issue 3
|
WJCO
|
www.wjgnet.com
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
SLA.0b013e31819a044f]
26 Boneti C, Yuen J, Santiago C, Diaz Z, Robertson Y, Korou-
rian S, Westbrook KC, Henry-Tillman RS, Klimberg VS.
Oncologic safety of nipple skin-sparing or total skin-sparing
mastectomies with immediate reconstruction. J Am Coll Surg
2011; 212: 686-93; discussion 693-5 [PMID: 21463813 DOI:
10.1016/j.jamcollsurg.2010.12.039]
27 Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mas-
tectomy in 99 patients with a mean follow-up of 5 years.
Ann Surg Oncol 2011; 18: 1665-1670 [PMID: 21174155 DOI:
10.1245/s10434-010-1475-4]
28 Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki
WM, Costa A. Necrotic complications after nipple- and
areola-sparing mastectomy. World J Surg 2006; 30: 1410-1413
[PMID: 16850148]
29 Warren Peled A, Foster RD, Stover AC, Itakura K, Ewing
CA, Alvarado M, Hwang ES, Esserman LJ. Outcomes after
total skin-sparing mastectomy and immediate reconstruc-
tion in 657 breasts. Ann Surg Oncol 2012; 19 : 3402-3409
[PMID: 22526909 DOI: 10.1245/s10434-012-2362-y]
30 Chen CM, Disa JJ, Sacchini V, Pusic AL, Mehrara BJ, Garcia-
Etienne CA, Cordeiro PG. Nipple-sparing mastectomy and
immediate tissue expander/implant breast reconstruction.
Plast Reconstr Surg 2009; 124: 1772-1780 [PMID: 19952633
DOI: 10.1097/PRS.0b013e3181bd05fd]
31 Teimourian B, Duda G. The propeller ap: a one-stage pro-
cedure for nipple-areola reconstruction. Aesthetic Plast Surg
1994; 18: 81-84 [PMID: 8122582]
32 Jabor MA, Shayani P, Collins DR, Karas T, Cohen BE. Nip-
ple-areola reconstruction: satisfaction and clinical determi-
nants. Plast Reconstr Surg 2002; 110: 457-63; discussion 464-5
[PMID: 12142660]
33 Munhoz AM, Aldrighi CM, Montag E, Arruda EG, Aldrighi
JM, Gemperli R, Filassi JR, Ferreira MC. Clinical outcomes
following nipple-areola-sparing mastectomy with immedi-
ate implant-based breast reconstruction: a 12-year experi-
ence with an analysis of patient and breast-related factors
for complications. Breast Cancer Res Treat 2013; 140: 545-555
[PMID: 23897416 DOI: 10.1007/s10549-013-2634-7]
34 Blechman KM, Karp NS, Levovitz C, Guth AA, Axelrod
DM, Shapiro RL, Choi M. The lateral inframammary fold in-
cision for nipple-sparing mastectomy: outcomes from over
50 immediate implant-based breast reconstructions. Breast J
; 19: 31-40 [PMID: 23252505 DOI: 10.1111/tbj.12043]
35 Rivolin A, Kubatzki F, Marocco F, Martincich L, Renditore S,
Maggiorotto F, Magistris A, Ponzone R. Nipple-areola com-
plex sparing mastectomy with periareolar pexy for breast
cancer patients with moderately ptotic breasts. J Plast Re-
constr Aesthet Surg 2012; 65: 296-303 [PMID: 22000331 DOI:
10.1016/j.bjps.2011.09.023]
36 Salibian AH, Harness JK, Mowlds DS. Inframammary ap-
proach to nipple-areola-sparing mastectomy. Plast Reconstr
Surg 2013; 132: 700e-708e [PMID: 24165622 DOI: 10.1097/
PRS.0b013e3182a4d64f]
37 Jensen JA. When can the nipple-areola complex safely be
spared during mastectomy? Plast Reconstr Surg 2002; 109:
805-807 [PMID: 11818873]
38 Laronga C, Kemp B, Johnston D, Robb GL, Singletary SE.
The incidence of occult nipple-areola complex involvement
in breast cancer patients receiving a skin-sparing mastec-
tomy. Ann Surg Oncol 1999; 6: 609-613 [PMID: 10493632]
39 Endara M, Chen D, Verma K, Nahabedian MY, Spear SL.
Breast reconstruction following nipple-sparing mastectomy:
a systematic review of the literature with pooled analysis.
Plast Reconstr Surg 2013; 132: 1043-1054 [PMID: 23924650
DOI: 10.1097/PRS.0b013e3182a48b8a]
40 Singletary SE, Robb GL. Oncologic safety of skin-sparing
mastectomy. Ann Surg Oncol 2003; 10 : 95-97 [PMID:
12620899]
41 Patani N, Mokbel K. Oncological and aesthetic consider-
ations of skin-sparing mastectomy. Breast Cancer Res Treat
2008; 111: 391-403 [PMID: 17965954]
42 Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and
areola involvement in breast cancer. Eur J Surg Oncol 1998;
24: 15-16 [PMID: 9542508]
43 Simmons RM, Brennan M, Christos P, King V, Osborne M.
Analysis of nipple/areolar involvement with mastectomy:
can the areola be preserved? Ann Surg Oncol 2002; 9: 165-168
[PMID: 11888874]
44 Murthy V, Chamberlain RS. Nipple-sparing mastectomy
in modern breast practice. Clin Anat 2013; 26: 56-65 [PMID:
23168689 DOI: 10.1002/ca.22185]
45 Santini D, Taffurelli M, Gelli MC, Grassigli A, Giosa F,
Marrano D, Martinelli G. Neoplastic involvement of nipple-
areolar complex in invasive breast cancer. Am J Surg 1989;
158: 399-403 [PMID: 2817219]
46 Menon RS, van Geel AN. Cancer of the breast with nipple
involvement. Br J Cancer 1989; 59: 81-84 [PMID: 2547416]
47 Verma GR, Kumar A, Joshi K. Nipple involvement in pe-
ripheral breast carcinoma: a prospective study. Indian J Can-
cer 1997; 34: 1-5 [PMID: 9491654]
48 Loewen MJ, Jennings JA, Sherman SR, Slaikeu J, Ebrom
PA, Davis AT, Fitzgerald TL. Mammographic distance as
a predictor of nipple-areola complex involvement in breast
cancer. Am J Surg 2008; 195: 391-34; discussion 391-34; [PMID:
18207131 DOI: 10.1016/j.amjsurg.2007.12.020]
49 Banerjee A, Gupta S, Bhattacharya N. Preservation of nip-
ple-areola complex in breast cancer--a clinicopathological
assessment. J Plast Reconstr Aesthet Surg 2008; 61: 1195-1198
[PMID: 17901007]
50 Voltura AM, Tsangaris TN, Rosson GD, Jacobs LK, Flores
JI, Singh NK, Argani P, Balch CM. Nipple-sparing mastec-
tomy: critical assessment of 51 procedures and implications
for selection criteria. Ann Surg Oncol 2008; 15: 3396-3401
[PMID: 18923874 DOI: 10.1245/s10434-008-0102-0]
51 Pir ozzi PR, Rossetti C, Carelli I, Ruiz CA, Pompei LM,
Piato S. Clinical and morphological factors predictive of
occult involvement of the nipple-areola complex in mastec-
tomy specimens. Eur J Obstet Gynecol Reprod Biol 2010; 148:
177-181 [PMID: 19926200 DOI: 10.1016/j.ejogrb.2009.10.021]
52 Reynolds C, Davidson JA, Lindor NM, Glazebrook KN,
Jakub JW, Degnim AC, Sandhu NP, Walsh MF, Hartmann
LC, Boughey JC. Prophylactic and therapeutic mastectomy
in BRCA mutation carriers: can the nipple be preserved?
Ann Surg Oncol 2011; 18: 3102-3109 [PMID: 21947588 DOI:
10.1245/s10434-011-1908-8]
53 Rusby JE, Brachtel EF, Othus M, Michaelson JS, Koerner
FC, Smith BL. Development and validation of a model pre-
dictive of occult nipple involvement in women undergoing
mastectomy. Br J Surg 2008; 95: 1356-1361 [PMID: 18844271
DOI: 10.1002/bjs.6349]
54 Wang J, Xiao X, Wang J, Iqbal N, Baxter L, Skinner KA,
Hicks DG, Hajdu SI, Tang P. Predictors of nipple-areolar
complex involvement by breast carcinoma: histopathologic
analysis of 787 consecutive therapeutic mastectomy speci-
mens. Ann Surg Oncol 2012; 19: 1174-1180 [PMID: 22006374
DOI: 10.1245/s10434-011-2107-3]
55 TURNER-WARWICK RT. The lymphatics of the breast. Br
J Surg 1959; 46: 574-582 [PMID: 13839973]
56 HANDLEY RS. THE EARLY SPREAD OF BREAST CAR-
CINOMA AND ITS BEARING ON OPERATIVE TREAT-
MENT. Br J Surg 1964; 51: 206-208 [PMID: 14129435]
57 Gerber B, Krause A, Reimer T, Müller H, Küchenmeister I,
Makovitzky J, Kundt G, Friese K. Skin-sparing mastectomy
with conservation of the nipple-areola complex and autolo-
gous reconstruction is an oncologically safe procedure. Ann
Surg 2003; 238: 120-127 [PMID: 12832974]
58 Foster RD, Esserman LJ, Anthony JP, Hwang ES, Do H.
Skin-sparing mastectomy and immediate breast reconstruc-
tion: a prospective cohort study for the treatment of ad-
492 August 10, 2014
|
Volume 5
|
Issue 3
|
WJCO
|
www.wjgnet.com
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
vanced stages of breast carcinoma. Ann Surg Oncol 2002; 9:
462-466 [PMID: 12052757]
59 Mallon P, Feron JG, Couturaud B, Fitoussi A, Lemasurier
P, Guihard T, Cothier-Savay I, Reyal F. The role of nipple-
sparing mastectomy in breast cancer: a comprehensive re-
view of the literature. Plast Reconstr Surg 2013; 131: 969-984
[PMID: 23629079 DOI: 10.1097/PRS.0b013e3182865a3c]
60 Sahin I, Isik S, Alhan D, Yıldız R, Aykan A, Ozturk E. One-
staged silicone implant breast reconstruction following bi-
lateral nipple-sparing prophylactic mastectomy in patients
at high-risk for breast cancer. Aesthetic Plast Surg 2013; 37:
303-311 [PMID: 23322096 DOI: 10.1007/s00266-012-0044-6]
61 Spe ar SL, Rottm an SJ, Seibo th LA, Hanna n CM. Bre ast
reconstruction using a staged nipple-sparing mastec-
tomy following mastopexy or reduction. Plast Reconstr
Surg 2012; 129: 572-581 [PMID: 22373964 DOI: 10.1097/
PRS.0b013e318241285c]
62 Djohan R, Gage E, Gatherwright J, Pavri S, Firouz J, Ber-
nard S, Yetman R. Patient satisfaction following nipple-spar-
ing mastectomy and immediate breast reconstruction: an
8-year outcome study. Plast Reconstr Surg 2010; 125: 818-829
[PMID: 20195110 DOI: 10.1097/PRS.0b013e3181ccdaa4]
63 Liu TS, Crisera CA, Festekjian JH, Da Lio AL. Staged wise-
pattern skin excision for reconstruction of the large and
ptotic breast. Plast Reconstr Surg 2010; 126: 1831-1839 [PMID:
21124123 DOI: 10.1097/PRS.0b013e3181f5278f]
64 Yiacoumettis AM. Two staged breast reconstruction follow-
ing prophylactic bilateral subcutaneous mastectomy. Br J
Plast Surg 2005; 58: 299-305 [PMID: 15780223]
65 Chung AP, Sacchini V. Nipple-sparing mastectomy: where
are we now? Surg Oncol 2008; 17: 261-266 [PMID: 18456492
DOI: 10.1016/j.suronc.2008.03.004]
66 Palmieri B, Baitchev G, Grappolini S, Costa A, Benuzzi G.
Delayed nipple-sparing modified subcutaneous mastecto-
my: rationale and technique. Breast J 2005; 11: 173-178 [PMID:
15871701]
67 Jensen JA, Lin JH, Kapoor N, Giuliano AE. Surgical delay of
the nipple-areolar complex: a powerful technique to maxi-
mize nipple viability following nipple-sparing mastectomy.
Ann Surg Oncol 2012; 19: 3171-3176 [PMID: 22829005 DOI:
10.1245/s10434-012-2528-7.]
68 Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing
mastectomy with immediate implant reconstruction: cos-
metic outcomes and technical refinements. Plast Reconstr
Surg 2010; 126: 1460-1471 [PMID: 21042102 DOI: 10.1097/
PRS.0b013e3181ef8bce]
69 Moyer HR, Ghazi B, Daniel JR, Gasgarth R, Carlson GW.
Nipple-sparing mastectomy: technical aspects and aesthetic
outcomes. Ann Plast Surg 2012; 68: 446-450 [PMID: 22531398
DOI: 10.1097/SAP.0b013e3182394bba]
70 Colwell AS, Gadd M, Smith BL, Austen WG. An inferolater-
al approach to nipple-sparing mastectomy: optimizing mas-
tectomy and reconstruction. Ann Plast Surg 2010; 65: 140-143
[PMID: 20606592 DOI: 10.1097/SAP.0b013e3181c1fe77]
71 Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ. Op-
timizing the total skin-sparing mastectomy. Arch Surg 2008;
143: 38-45; discussion 45 [PMID: 18209151 DOI: 10.1001/
archsurg.143.1.38]
72 Proano E, Perbeck LG. Inuence of the site of skin incision
on the circulation in the nipple-areola complex after subcu-
taneous mastectomy in breast cancer. Scand J Plast Reconstr
Surg Hand Surg 1996; 30: 195-200 [PMID: 8885014]
73 Toth BA, Daane SP. Purse-string mastectomy with imme-
diate prosthetic reconstruction: an improved skin-sparing
technique for small breasts. Plast Reconstr Surg 2003; 111:
2333-2337 [PMID: 12794477]
74 Hammond DC, Capraro PA, Ozolins EB, Arnold JF. Use
of a skin-sparing reduction pattern to create a combination
skin-muscle ap pocket in immediate breast reconstruction.
Plast Reconstr Surg 2002; 110: 206-211 [PMID: 12087255]
75 Rusby JE, Gui GP. Nipple-sparing mastectomy in women
with large or ptotic breasts. J Plast Reconstr Aesthet Surg
2010; 63 : e754-e755 [PMID: 20598664 DOI: 10.1016/
j.bjps.2010.06.002]
76 Niemeyer M, Paepke S, Schmid R, Plattner B, Müller D,
Kiechle M. Extended indications for nipple-sparing mas-
tectomy. Breast J 2011; 17: 296-299 [PMID: 21450018 DOI:
10.1111/j.1524-4741.2011.01079.x]
77 Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complica-
tions in postmastectomy breast reconstruction: two-year re-
sults of the Michigan Breast Reconstruction Outcome Study.
Plast Reconstr Surg 2002; 109: 2265-2274 [PMID: 12045548]
78 Gamboa-Bobadilla GM, Killingsworth C. Large-volume
reduction mammaplasty: the effect of body mass index
on postoperative complications. Ann Plast Surg 2007; 58:
246-249 [PMID: 17471126]
79 Woerdeman LA, Hage JJ, Hoand MM, Rutgers EJ. A pro-
spective assessment of surgical risk factors in 400 cases of
skin-sparing mastectomy and immediate breast reconstruc-
tion with implants to establish selection criteria. Plast Recon-
str Surg 2007; 119: 455-463 [PMID: 17230076]
80 Bailey MH, Smith JW, Casas L, Johnson P, Serra E, de la
Fuente R, Sullivan M, Scanlon EF. Immediate breast recon-
struction: reducing the risks. Plast Reconstr Surg 1989; 83:
845-851 [PMID: 2710833]
81 Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors
affecting post-operative complications following skin
sparing mastectomy with immediate breast reconstruc-
tion. Breast 2011; 20: 21-25 [PMID: 20619645 DOI: 10.1016/
j.breast.2010.06.006]
82 Spear SL, Hannan CM, Willey SC, Cocilovo C. Nipple-
sparing mastectomy. Plast Reconstr Surg 2009; 123: 1665-1673
[PMID: 19483564 DOI: 10.1097/PRS.0b013e3181a64d94]
83 Mosahebi A, Ramakrishnan V, Gittos M, Collier J. Aesthetic
outcome of different techniques of reconstruction following
nipple-areola-preserving envelope mastectomy with imme-
diate reconstruction. Plast Reconstr Surg 2007; 119: 796-803
[PMID: 17312480]
84 Grotting JC, Urist MM, Maddox WA, Vasconez LO. Con-
ventional TRAM ap versus free microsurgical TRAM ap
for immediate breast reconstruction. Plast Reconstr Surg
1989; 83: 828-41; discussion 842-4 [PMID: 2523544]
85 Feller AM, Hörl HW, Biemer E. The transverse rectus ab-
dominis musculocutaneous free ap: a reliable alternative
for delayed autologous tissue breast reconstruction. Ann
Plast Surg 1990; 25: 425-434 [PMID: 2149916]
86 Kroll SS, Marchi M. Comparison of strategies for prevent-
ing abdominal-wall weakness after TRAM ap breast recon-
struction. Plast Reconstr Surg 1992; 89: 1045-151; discussion
1045-151; [PMID: 1533942]
87 Schusterman MA, Kroll SS, Weldon ME. Immediate breast
reconstruction: why the free TRAM over the conventional
TRAM ap? Plast Reconstr Surg 1992; 90: 255-61; discussion
262 [PMID: 1631217]
88 Elliott LF, Eskenazi L, Beegle PH, Podres PE, Drazan L. Im-
mediate TRAM ap breast reconstruction: 128 consecutive
cases. Plast Reconstr Surg 1993; 92: 217-227 [PMID: 8337270]
89 Koshima I, Soeda S. Inferior epigastric artery skin flaps
without rectus abdominis muscle. Br J Plast Surg 1989; 42:
645-648 [PMID: 2605399]
90 Allen RJ, Treece P. Deep inferior epigastric perforator ap
for breast reconstruction. Ann Plast Surg 1994; 32: 32-38
[PMID: 8141534]
91 Blondeel PN. One hundred free DIEP flap breast recon-
structions: a personal experience. Br J Plast Surg 1999; 52:
104-111 [PMID: 10434888]
92 Munhoz AM, Ishida LH, Sturtz GP, Cunha MS, Montag E,
Saito FL, Gemperli R, Ferreira MC. Importance of lateral
row perforator vessels in deep inferior epigastric perforator
ap harvesting. Plast Reconstr Surg 2004; 113: 517-524 [PMID:
493 August 10, 2014
|
Volume 5
|
Issue 3
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|
www.wjgnet.com
Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
14758211]
93 Munhoz AM, Ishida LH, Montag E, Sturtz GP, Saito FL, Ro-
drigues L, Gemperli R, Ferreira MC. Perforator ap breast
reconstruction using internal mammary perforator branches
as a recipient site: an anatomical and clinical analysis. Plast
Reconstr Surg 2004; 114: 62-68 [PMID: 15220570]
94 Munhoz AM, Sturtz G, Montag E, Arruda EG, Aldrighi C,
Gemperli R, Ferreira MC. Clinical outcome of abdominal
wall after DIEP ap harvesting and immediate application
of abdominoplasty techniques. Plast Reconstr Surg 2005; 116:
1881-1893 [PMID: 16327599]
95 Yang SJ, Eom JS, Lee TJ, Ahn SH, Son BH. Recipient ves-
sel selection in immediate breast reconstruction with free
abdominal tissue transfer after nipple-sparing mastectomy.
Arch Plast Surg 2012; 39: 216-221 [PMID: 22783529 DOI:
10.5999/aps.2012.39.3.216.]
96 Kim HJ, Park EH, Lim WS, Seo JY, Koh BS, Lee TJ, Eom
JS, Lee SW, Son BH, Lee JW, Ahn SH. Nipple areola skin-
spari ng mastec tomy with immediat e tr an sverse rectus
abd omini s musculocutaneous flap reconstruction is an
oncologically safe procedure: a single center study. Ann
Surg 2010; 251: 493-498 [PMID: 20134317 DOI: 10.1097/
SLA.0b013e3181c5dc4e]
97 Gui GP, Tan SM, Faliakou EC, Choy C, A’Hern R, Ward
A. Immediate breast reconstruction using biodimensional
anatomical permanent expander implants: a prospective
analysis of outcome and patient satisfaction. Plast Reconstr
Surg 2003; 111: 125-38; discussion 139-40 [PMID: 12496573]
98 Maxwell GP. Immediate breast reconstruction using biodi-
mensional anatomical permanent expander implants: a
prospective analysis of outcome and patient satisfaction
(discussion). Plast Reconstr Surg 2003; 111: 139-145
99 Mahdi S, Jones T, Nicklin S, McGeorge DD. Expandable
anatomical implants in breast reconstructions: a prospective
study. Br J Plast Surg 1998; 51: 425-430 [PMID: 9849361]
100 Mandrekas AD, Zambacos GJ, Katsantoni PN. Immediate
and delayed breast reconstruction with permanent tissue
expanders. Br J Plast Surg 1995; 48: 572-578 [PMID: 8548159]
101 Salgarello M, Seccia A, Eugenio F. Immediate breast recon-
struction with anatomical permanent expandable implants
after skin-sparing mastectomy: aesthetic and technical re-
nements. Ann Plast Surg 2004; 52: 358-64; discussion 365-6
[PMID: 15084878]
102 Hayes AJ, Jenkins MP, Sandhu SS, Baum M. Subpectoral
breast reconstruction using the biodimensional system. Ann
R Coll Surg Engl 1997; 79: 355-360 [PMID: 9326128]
103 Paepke S, Schmid R, Fleckner S, Paepke D, Niemeyer M,
Schmalfeldt B, Jacobs VR, Kiechle M. Subcutaneous mas-
tectomy with conservation of the nipple-areola skin: broad-
ening the indications. Ann Surg 2009; 250: 288-292 [PMID:
19638905 DOI: 10.1097/SLA.0b013e3181b0c7d8]
104 Petit JY, Veronesi U, Orecchia R, Luini A, Rey P, Intra M,
Didier F, Martella S, Rietjens M, Garusi C, DeLorenzi F,
Gatti G, Leon ME, Casadio C. Nipple-sparing mastectomy
in association with intra operative radiotherapy (ELIOT): A
new type of mastectomy for breast cancer treatment. Breast
Cancer Res Treat 2006; 96: 47-51 [PMID: 16261402]
105 Benediktsson KP, Perbeck L. Survival in breast cancer after
nipple-sparing subcutaneous mastectomy and immediate
reconstruction with implants: a prospective trial with 13
years median follow-up in 216 patients. Eur J Surg Oncol
2008; 34: 143-148 [PMID: 17709228]
106 Bistoni G, Rulli A, Izzo L, Noya G, Alfano C, Barberini F.
Nipple-sparing mastectomy. Preliminary results. J Exp Clin
Cancer Res 2006; 25: 495-497 [PMID: 17310839]
107 Babiera G, Simmons R. Nipple-areolar complex-sparing
mastectomy: feasibility, patient selection, and technique.
Ann Surg Oncol 2010; 17 Suppl 3: 245-248 [PMID: 20853041
DOI: 10.1245/s10434-010-1256-0]
108 Spear SL, Willey SC, Feldman ED, Cocilovo C, Sidawy M,
Al-Attar A, Hannan C, Seiboth L, Nahabedian MY. Nipple-
sparing mastectomy for prophylactic and therapeutic in-
dications. Plast Reconstr Surg 2011; 128: 1005-1014 [PMID:
21738086 DOI: 10.1097/PRS.0b013e31822b6456]
109 Petit JY, Veronesi U, Orecchia R, Rey P, Martella S, Didier
F, Viale G, Veronesi P, Luini A, Galimberti V, Bedolis R, Ri-
etjens M, Garusi C, De Lorenzi F, Bosco R, Manconi A, Ival-
di GB, Youssef O. Nipple sparing mastectomy with nipple
areola intraoperative radiotherapy: one thousand and one
cases of a ve years experience at the European institute of
oncology of Milan (EIO). Breast Cancer Res Treat 2009; 117:
333-338 [PMID: 19152026 DOI: 10.1007/s10549-008-0304-y]
P- Reviewer: Heo CY, Jun Y S- Editor: Ji FF L- Editor: A
E- Editor: Lu YJ
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Volume 5
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Munhoz AM
et al
. Immediate nipple-areola-sparing mastectomy reconstruction
