A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-based Breast Reconstructions

Abstract

Background: Nipple-sparing mastectomy is commonly performed for breast cancer treatment or prevention. The authors present one of the largest breast reconstruction series in the literature. Methods: A single-institution retrospective review was conducted from 2007 to 2019. Results: The authors’ query identified 3035 implant-based breast reconstructions after nipple-sparing mastectomy, including 2043 direct-to-implant and 992 tissue expander–to-implant reconstructions. The overall major complication rate was 9.15%, and the nipple necrosis rate was 1.20%. Therapeutic mastectomy was associated with higher overall complications and explantations compared with prophylactic mastectomy (P < 0.01). In comparisons of unilateral and bilateral procedures, bilateral mastectomy had an increased risk for complications (OR, 1.46; 95% CI, 0.997 to 2.145; P = 0.05). Tissue-expander reconstructions had higher rates of nipple necrosis (1.9% versus 0.88%; P = 0.015), infection (4.2% versus 2.8%; P = 0.04), and explantation (5.1% versus 3.5%; P = 0.04) compared with direct-to-implant reconstruction. When assessing plane of reconstruction, the authors found similar rates of complications between subpectoral dual-plane and prepectoral reconstruction. There was no difference in complications between reconstruction with acellular dermal matrix or mesh compared with total or partial muscle coverage without acellular dermal matrix/mesh (OR, 0.749; 95% CI, 0.404 to 1.391; P = 0.361). Multivariable regression analysis revealed preoperative radiotherapy (OR, 2.465; 95% CI, 1.579 to 3.848; P < 0.001), smoking (OR, 2.53; 95% CI, 1.581 to 4.054; P < 0.001), and a periareolar incision (OR, 3.657; 95% CI, 2.276 to 5.875; P < 0.001) to be the strongest predictors of complications and nipple necrosis (P < 0.05). Conclusions: Nipple-sparing mastectomy and immediate breast reconstruction has a low rate of complications. In this series, radiation therapy, smoking, and incision choice predicted overall complications and nipple necrosis, whereas direct-to-implant reconstruction and acellular dermal matrix or mesh did not increase risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions

“…It has been demonstrated that acellular matrices undergo neo-vascularization and recellularization by host cells ( 19 - 21 ). In breast reconstruction, ADMs are used to enhance skin coverage, particularly after the placement of a silicone implant or tissue expander ( 4 , 22 ). Another goal is to reduce the risk of capsule contracture, a significant complication of implant-based surgeries, leading to a substantial decrease in the long-term cosmetic result ( 23 ).…”

“…A retrospective review conducted over ten years at the Massachusetts General Hospital included more than 3,000 patients undergoing breast reconstruction ( 4 ). One aspect of their analysis compared the outcomes of pre-pectoral implant reconstruction with ADM-enhanced coverage versus subpectoral techniques, where the implant is placed partially under the muscle.…”

“…In contrast, nipple-sparing mastectomy (NSM) is a surgical technique that involves removing the breast tissue while sparing the nipple and areola complex ( 3 ). NSM is not considered a safe option for all breast cancer subtypes and cases, particularly those with multifocal tumors or hormone receptor-negative/ERBB2-positive subtypes ( 4 , 5 ). In such cases, total mastectomy remains the gold standard therapy.…”

Discussion: A Decade of Nipple-Sparing Mastectomy: Lessons Learned in 3035 Immediate Implant-Based Breast Reconstructions

“…This is true in face lifts, free flaps, and-as is demonstrated again in this article-implant-based mastectomy reconstruction. The breast program at Massachusetts General Hospital delivers an exceptional article 1 and there is a lot to unpack. The most important concept to understand, is that this is not a randomized clinical trial, and the outcomes reflect the science and art of a highly skilled and experienced team navigating patients through a complex process.…”

Artistry and Aesthetics in Breast Reconstruction: Raising the Bar

“…Immediate breast reconstruction (IBR) using free flaps after nipple-sparing and skin-reducing mastectomies can provide natural-looking outcomes in a one-step surgical approach, providing several advantages for both the patient and the healthcare system, in a time- and cost-effective way. Indeed, studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress, and lower treatment costs in IBR [ 4 ]. Finally, in the last decade, lymphatic surgery advancements have become extremely popular and have also affected the breast reconstruction journey.…”