Nipple-Sparing Mastectomy: Technique and Results of 54 Procedures
Departments of General Surgery and Plastic Surgery, The Cleveland Clinic Breast Center, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. Archives of Surgery
(Impact Factor: 4.93).
03/2004; 139(2):148-50. DOI: 10.1001/archsurg.139.2.148
The rationale for removal of the nipple-areolar complex (NAC) during total mastectomy centers on long-standing concerns about possible neoplastic involvement of the NAC and its postoperative viability. Nipple-sparing mastectomy (NSM) combines a skin-sparing mastectomy with preservation of the NAC, intraoperative pathological assessment of the nipple tissue core, and immediate reconstruction, thereby permitting better cosmesis for patients undergoing total mastectomy. Neoplastic involvement of the NAC can be predicted before surgery and assessed during the operation, and sustained postoperative viability of the NAC is likely with appropriate surgical technique.
Fifty-four NSMs with immediate reconstruction were attempted among 44 patients. Six NAC core specimens revealed neoplastic involvement on frozen section analysis, resulting in conversion to total mastectomies. Forty-five of the 48 completed NSMs maintained postoperative viability of the NAC; 3 NACs had partial loss.
Nipple-sparing mastectomy is a reasonable option for carefully screened patients.
Available from: Jean Yves Petit
- "Skin incision types are not related to necrotic complications in our study. Several studies have shown that incision types are an important risk factor of NAC necrosis.13,17,29,30 Regolo et al31 reported of 60% NAC loss with the periareolar incision. "
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Nipple sparing mastectomy (NSM) can be performed for prophylactic mastectomy and the treatment of selected breast cancer with oncologic safety. The risk of skin and nipple necrosis is a frequent complication of NSM procedure, and it is usually related to surgical technique. However, the role of the breast morphology should be also investigated.
We prospectively performed an analysis of 124 NSM from September 2012 to January 2013 at the European Institute of Oncology, Milan, Italy, focusing on necrotic complications. We analyzed the association between the risks of skin necrosis and the breast morphology of the patients.
Among 124 NSM in 113 patients, NSM procedures were associated with necrosis in 22 mastectomies (17.7%) among which included partial necrosis of nipple-areolar complex (NAC) in 15 of 124 NSM (12.1%) and total necrosis in 4 cases (3.5%). The NAC was removed in 5 NSM cases (4%). The volume of breast removed was the only significant factor increasing the risk of skin necrosis. The degree of ptosis was not significantly related to the necrosis risk.
Large glandular specimen increases the risk of NAC necrosis. The degree of ptosis and the distance between the sternal notch and the NAC have no significant impact on necrotic complications in NSM. To reduce the necrotic complications in large breast after NSM, reconstruction should better be performed with autologous flap or slow skin expansion using the expander technique.
Available from: Jessica Wang-Rodriguez
- "2003 27 3.7% total, 7.4% partial Gerber et al.  2003 112 0% total, 9.8% partial Crowe et al.  2004 54 0% total, 6% partial Medial led to all 3 losses (6%), then used lateral Petit et al.  "
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ABSTRACT: Breast conservation therapy has been the cornerstone of the surgical treatment of breast cancer for the last 20 years; however, recently, the use of mastectomy has been increasing. Mastectomy is one of the most frequently performed breast operations, and with novel surgical techniques, preservation of the skin envelope and/or the nipple-areolar complex is commonly performed. The goal of this paper is to review the literature on skin-sparing mastectomy and nipple-sparing mastectomy and to evaluate the oncologic safety of these techniques. In addition, this paper will discuss the oncologic importance of margin status and type of mastectomy as it pertains to risk of local recurrence and relative need for adjuvant therapy.
Available from: David G Hicks
- "However, these techniques are not perfect; and there are still both false positive and false negative cases associated with them.23,31 Intraoperative retroareolar en-face margin assessment may be used to detect occult tumor involvement in patients undergoing NSM.14,23 Nipple needle core biopsies have also been performed to evaluate possible occult NAC involvement intraoperatively.13 "
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ABSTRACT: Breast-conserving therapy (BCT) is an accepted therapeutic option for most breast cancer patients. However, mastectomy is still performed in 30-50% of patients undergoing surgeries. There is increasing interest in preservation of the nipple and/or areola in hopes of achieving improved cosmetic and functional outcomes; however, the oncologic safety of nipple-areolar complex (NAC) preservation is a major concern. We sought to identify the predictive factors for NAC involvement in breast cancer patients.
We analyzed the rates and types of NAC involvement by breast carcinoma, and its association with other clinicopathologic features of the tumors in 787 consecutive therapeutic mastectomies performed at our institution between 1997 and 2009.
Among these, 75 cases (9.5%) demonstrated NAC involvement. Only 21 (28%) of 75 of cases with NAC involvement could be identified grossly by inspection of the surgical specimen (seven of these had been clinically identified). NAC involvement was most significantly associated with tumors located in all four quadrants (P<0.0001), tumors>5 cm in size (P=0.0014 for invasive carcinoma and P=0.0032 for in-situ carcinoma), grade 3 tumors (P=0.0192), tumors with higher nuclear grades (P=0.0184), and tumors with HER2 overexpression (P=0.0137).
On the basis of our findings, we have developed a mathematical model that is based on the extent and location of the tumor, HER2 expression, and nuclear grade that predicts the probability of NAC involvement by breast cancer. This model may aid in preoperative planning in selecting appropriate surgical procedures based on an individual patient's relative risk of NAC involvement.
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