Breast Reconstruction and Nipple-Sparing Mastectomy

Abstract

Background Superior aesthetic outcomes can be achieved with mastectomy techniques that maximize breast envelope preservation and maintain the nipple-areolar complex. This is the impetus for the popularization of the nipple-sparing mastectomy (NSM). Nipple-sparing mastectomy is a challenging procedure due to potential ischemia of the mastectomy flap (which includes the nipple-areolar complex) and the risk of incomplete oncologic resection. We review our experience with NSM, identify technique modifications used over time, and evaluate reconstructive outcomes of NSM and its modifications. Methods A retrospective review of consecutive patients with NSM and breast reconstruction over an 8-year period was completed. Results Fifty-five patients underwent 95 NSMs. Indications included invasive and in situ cancer, atypical ductal hyperplasia, and risk reduction. In the first 4 years of experience, the most frequently used NSM incision was radial (lateral) whereas use of a variety of incision patterns was noted in the second 4 years. Overall NSM and breast reconstruction complication rate for the entire study period was 50.9% and included a full-thickness mastectomy skin flap necrosis/nipple necrosis rate of 8.4%. In situ cancer of the nipple was identified in 3.2% of the patients, and 1 patient had locoregional recurrence. Overall complication rate was lower in the second 4 years of experience with NSM and reconstruction. One third of the patients underwent intraoperative fluorescent angiography (FA) to assess mastectomy skin perfusion before reconstruction start. Of the patients who had FA due to perfusion concerns, more than 70% of studies demonstrated poor perfusion and 83.3% of these patients had reconstruction delayed based on these results. Immediate, implant-based reconstruction was performed most commonly. An average of 2.66 procedures were required to achieve reconstruction completion, and 92.4% of the patients who sought reconstruction achieved completion. Conclusions At our institution, NSM use is increasing, NSM incision pattern types used are expanding, and complication rates are decreasing. Immediate, implant-based reconstruction is most commonly used in combination with NSM at our institution. Fluorescent angiography is used to assess mastectomy skin perfusion and likely limits mastectomy complication effects on reconstruction. Despite the occurrence of complications, most patients will complete the breast reconstruction process.

Comparative Analysis of Nipple Reconstruction Techniques: Five Flap vs. C-V Flap

“…This is particularly evident when considering the timing of nipple reconstruction, where timely intervention can significantly improve a patient's psychological state and overall satisfaction with the procedure. 7 , 8 , 9 , 10 …”

“…It's crucial to acknowledge that nipple reconstruction, like any surgical procedure, carries certain risks and potential complications, such as infection, bruising, delayed wound healing, and complete or partial nipple necrosis. 7 The choice of surgical technique ultimately rests with the surgeon, who makes this decision based on their experience and the patient's preferences.…”

Outcomes of Nipple-Sparing Mastectomy in the Ptotic and Non-Ptotic Breast with Staged-Immediate Reconstruction Timing and Pre-Pectoral, Direct-to-Implant Technique

“…As a result, direct-to-final implant reconstruction without expansion is also becoming more common. Furthermore, pre-pectoral implant placement is gaining popularity as it avoids animation deformity, is associated with less postoperative pain, and improved cosmetic outcomes [ 2 , 13 ]. However, inappropriate application of this technique may result in serious complications such as implant loss and the subsequent need for unplanned or additional operative procedures.…”

Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI

“…The limitations of this study are due to the relatively small sample size, which may have caused the inability to determine the impact of other factors such as BMI and RT on clinical outcomes. Possibly, the IMP‐NSM technique may change the previously described impact of these factors [11, 12, 14, 24, 25]. Future studies of NSM necrosis complications should describe management of the IMP as an important variable that can be modified to decrease necrosis.…”

“…However, despite these clear anatomical descriptions indicating the importance of IMP preservation, the optimal surgical technique and success rate of IMP preservation during NSM, is not usually reported in clinical studies investigating the rate of ischemic complications following NSM [11][12][13][14]. Breast magnetic resonance imaging (MRI) with contrast, often obtained for preoperative oncologic assessment of tumor extent, or high-risk screening, can also demonstrate breast blood flow patterns with clinical relevance to ischemic complications [6].…”