Aesthetic Outcomes and Complications of Immediate Breast Reconstruction After Nipple-Sparing Mastectomy
Janet H. Yueh, BA, Mary Jane Houlihan, MD, Sumner A. Slavin, MD, Bernard T. Lee, MD, Donald J. Morris, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Background: Current trends in the treatment of breast cancer reveal a progressively higher value being placed on the conservation of normal tissues. Skin-sparing mastectomy allows the preservation of the breast skin envelope, thus improving the aesthetic results of ensuing reconstruction. Preservation of the nipple-areolar complex (NAC) further improves the advantages of skin-sparing mastectomy. While nipple-sparing mastectomy (NSM) is better known in Europe, this technique continues to remain highly controversial in North America. Reported rates of neoplastic involvement of the NAC vary from 0-58%. Although these studies have concluded that the overall rate of involvement is unacceptably high, it has been hypothesized that NSM may be oncologically safe in carefully selected patients. The purpose of this study is to describe our institution’s experience with NSM and immediate reconstruction, with particular attention to surgical technique, neoplastic assessment of the NAC, postoperative NAC viability, and aesthetic results.
Methods: From April 2000 to October 2007, 9 consecutive patients underwent unilateral or bilateral NSM (15 breasts) with immediate reconstruction. Whether considering NSM for breast cancer treatment or prophylaxis, preoperative screening included clinical breast exam, review of imaging, and patient informed consent. For patients with invasive cancer or ductal carcinoma in situ, diagnosis had been made previously by surgical excision biopsy. Initial incisions were made at the inframammary crease or partially circumareolar. Coring out the nipple was routinely performed. Reconstruction was performed with either an implant or autologous tissue flap. After the procedures, all patients were followed up for an average of 28 months by a surgical oncologist and plastic surgeon for evidence of recurrence. A survey assessing the satisfaction of the breast reconstruction was sent out to all patients.
Results: 13 NSMs were performed for breast cancer prophylaxis, 1 for DCIS, and 1 for infiltrating ductal carcinoma. All reconstructions were immediate, 11 of which were done with implants, 2 with tissue expanders, 1 pedicle transverse rectus abdominis myocutaneous flap, and 1 deep inferior epigastric perforator flap. Short term complications included partial loss of the NAC (1 breast), which required debridement. In one case, bilateral NSMs were performed for LCIS. Despite a normal preoperative mammogram and breast MRI, pathology of the mastectomy specimens revealed a 5 mm focus of high grade DCIS beneath one nipple. Due to the possibility of neoplastic involvement of the NAC, both nipple-areolar complexes were excised, and pathology showed no residual DCIS. While all patients were satisfied with their overall reconstructive experience, 6 patients were aesthetically satisfied with their breast reconstruction and 3 were not. At this time there have been no instances of local recurrence or distant disease.
Conclusions: NSM has begun to play a role in the prophylactic removal of breast tissue and treatment of cancer at our institution. The preservation of the entire skin envelope, including the NAC, appears to enhance and simplify the results of immediate breast reconstruction. While our series of patients report high satisfaction rates with few complications, longer follow up and a larger patient cohort is required to assess the long term oncologic safety.