Current Evidence on Surgical Approach to Local Recurrence After Nipple-Sparing Mastectomy: Is It Time to Classify in Order to Decide Better?

Although it is intuitive that nipple-sparing mastectomy in selected patients would result in excellent cosmetic outcomes and high patient satisfaction, studies of clinical outcomes and health-related quality of life are limited and show mixed results. This study aimed to use a propensity score-matching analysis to compare satisfaction and health-related quality-of-life outcomes in patients who underwent implant-based reconstruction following bilateral nipple-sparing mastectomy or skin-sparing mastectomy. A propensity score-matching analysis (1:1 matching, no replacement) was performed comparing patients undergoing nipple-sparing or skin-sparing mastectomy with immediate bilateral implant-based breast reconstruction. Patients with a history of any radiation therapy were excluded. Matched covariates included age, body mass index, race, smoking history, neoadjuvant chemotherapy, bra size, and history of psychiatric diagnosis. Outcomes of interest included BREAST-Q scores and complications. The authors examined 1371 patients for matching and included 460 patients (nipple-sparing mastectomy, n = 230; skin-sparing mastectomy, n = 230) in the final analyses. The authors found no significant differences in baseline, cancer, and surgical characteristics between matched nipple-sparing and skin-sparing mastectomy patients, who also had similar profiles for surgical complications. Interestingly, the authors found that postoperative Satisfaction with Breasts scores and all other health-related quality-of-life domains were stable over a 3-year period and did not differ significantly between the two groups. Compared with skin-sparing mastectomy, bilateral nipple-sparing mastectomy did not improve patient-reported or clinical outcomes when combined with immediate implant-based reconstruction. The impact that nipple-sparing mastectomy may have on breast aesthetics and the ability of the BREAST-Q to gauge an aesthetic result following nipple-sparing mastectomy warrant further investigation. Therapeutic, III.

PURPOSE: Nipple-sparing mastectomy (NSM) preserves natural nipple-areola complex and entire native breast skin with a goal of better cosmetic outcomes in breast reconstruction. In bilateral tissue expander (TE)/implant-based reconstruction requiring unilateral post-mastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared to skin-sparing mastectomy (SSM). This study compares, 1) surgical complications, 2) patient satisfaction, and 3) aesthetic outcomes between NSM vs. SSM in bilateral implant-based reconstruction with unilateral PMRT. METHOD: This retrospective matched cohort study included consecutive NSM patients with TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. All patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, co-morbidities, and complication data were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcome was assessed by blinded reviewers with a 5-point Likert scale. RESULTS: Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, BMI, and co-morbidities. No significant difference existed between overall surgical complications (p=0.2) and BREAST-Q questionnaire scores. The average adverse effects of radiation score was higher in the NSM. Preliminary aesthetic outcomes demonstrated higher total average aesthetic score in SSM compared to NSM. CONCLUSION: Although NSM is generally associated with better cosmetic outcome compared to SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT. This may be related to the additional negative post-radiotherapy impact on nipple asymmetry.

It has been reported that immediate autologous tissue breast reconstruction after nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) is esthetically superior to autologous tissue reconstruction after conventional mastectomy (CM). We evaluated reconstructed breasts to determine whether these methods contribute to breast appearance other than skin texture. Between April 1992 and September 2001, forty-two patients underwent immediate breast reconstruction using autologous tissue. Mastectomy options were NSM, SSM and CM. Postoperative photographs were evaluated using a subscale (volume, contour, placement, and inframammary fold) on a 0-2 point scale. Sternal notch to nipple distances of the affected and normal sides were measured with photographs to estimate nipple-areola complex (NAC) position. No corrective procedure was performed in a later phase before evaluation. NSM was performed in 22, SSM in 6 and CM in 14 cases. On esthetic evaluation, the NSM and SSM groups received 4.96 and the CM group received 4.63. There were no significant differences. In the NSM and SSM group, the NAC position rose in cases with partial necrosis or fat lysis compared with the no complication group (p = 0,004). Autologous tissue breast reconstruction after NSM or SSM is esthetically equal to autologous tissue reconstruction after CM with regard to parameters other than skin texture. Preserved or simultaneously reconstructed NAC sometimes emphasizes nipple-areola asymmetry when breast deformity has occurred.

Skin sparing mastectomy, a surgical procedure sparing a large portion of the overlying skin of the breast, and nipple-sparing mastectomy, sparing the whole nipple-areolar complex, are increasingly used, although their oncologic efficacy remains unclear. The aim of this study was to assess the radiation oncologists' opinions regarding the indications of radiation therapy (RT) after skin-sparing mastectomy and nipple-sparing mastectomy. Radiation oncology members of four national and international societies were invited to complete a questionnaire comprising of 22 questions to assess their opinions regarding RT indications in the context of skin-sparing and nipple-sparing mastectomy. A total of 298 radiation oncologists answered the questionnaire. 90.9% of respondents affirmed that breast cancer is one of their specializations. The majority declared that post-mastectomy RT is indicated for early-stage (stages I and II) breast cancer patients who present with risk factors for recurrence after skin-sparing or nipple-sparing mastectomy (87.2% and 80.2%, respectively). All suggested risk factors (tumor size, lymph node involvement, extracapsular extension, lymphovascular space invasion, positive surgical margins, triple negative tumor, multicentric tumor, and age) were considered as major elements (important or very important). There is no consensus regarding the necessity of evaluating residual breast tissue or the definition of residual breast tissue after mastectomy. All classic factors were considered as major elements, potentially influencing the decision to advice or not postoperative RT. Many uncertainties remain about the indications for RT after skin-sparing mastectomy or nipple-sparing mastectomy.

Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) are widely accepted surgical options for breast cancer patients undergoing immediate reconstruction. However, the impact of preserving the nipple–areolar complex on patient-reported outcomes (PROs) remains uncertain, particularly in clinically matched settings. This retrospective study included patients who underwent unilateral NSM or SSM followed by immediate implant-based breast reconstruction at Hubei Cancer Hospital between January 2022 and January 2024. Patients were propensity score matched (2:1) based on age, body mass index, preoperative breast size, neoadjuvant chemotherapy, implant plane, and postmastectomy radiation therapy. PROs were assessed using the BREAST-Q (version 2.0) and the decision regret scale. Univariate and multivariate linear regression analyses were conducted to identify predictors of satisfaction and regret. A total of 87 patients were included after matching (NSM: n = 58; SSM: n = 29). NSM patients reported significantly higher satisfaction with breasts (mean 58.1 vs. 52.9, P = 0.038) and sexual well-being (mean 52.4 vs. 38.9, P = 0.035). Although psychosocial well-being and decision regret showed favorable trends in the NSM group, differences were not statistically significant. Multivariate analysis revealed that reduction in breast size was significantly associated with decreased satisfaction and psychosocial well-being, while increased breast size was linked to greater decision regret. No significant differences were observed in complication rates between groups. Notably, none of the SSM patients received nipple reconstruction during follow-up. NSM was associated with greater satisfaction in breast and sexual well-being compared to SSM in matched breast cancer patients undergoing implant-based reconstruction. These findings support prioritizing NSM when oncologically feasible and highlight the potential role of delayed nipple reconstruction and expectation management in improving postoperative satisfaction for SSM patients.

To find out if skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM) with immediate autologous reconstruction as safe in oncological terms as modified radical mastectomy (MRM). The oncological safety of less radical surgical procedures like SSM and NSM cannot be evaluated by randomized trials. A careful and long lasting follow-up of patients, treated with SSM or NSM, is urgently needed. Between 1994-2000, 246 selected patients with an indication for MRM were treated with SSM, NSM, or MRM. Short term results were published in 2003. After a mean follow-up of 101 months (range 32-126), 238 evaluable patients with SSM (N = 48), NSM (N = 60), or MRM (N = 130) were analyzed for local and distant recurrences, breast cancer specific death, and esthetic results. Local recurrences occurred in 10.4% (SSM), 11.7% (NSM) and 11.5% (MRM) of all patients (P = 0.974). With regard to isolated DM (25.0%, 23.3%, respectively 26.2%; P = 0.916) and breast cancer specific death (20.8%, 21.7%, respectively 21.5%; P = 0.993), there were no significant differences between subgroups. The re-evaluation of esthetic results by surgeons revealed a significant shift from 78.4% excellent results after 59 months to 47.9% after 101 months follow-up (SSM; P = 0.004) and from 73.8% to 51.7% (NSM; P = 0.025). An important risk factor for decreased cosmetic score was application of adjuvant radiotherapy. In patients who are candidates for a mastectomy, skin sparing mastectomy or nipple sparing mastectomy with immediate autologous reconstruction are oncologically safe techniques. Adjuvant radiotherapy decreases the esthetic results even after a longer period of time.

Nipple-sparing mastectomy (NSM) preserves the natural nipple-areola complex and entire native breast skin, with the goal of better cosmetic outcomes in breast reconstruction. In bilateral TE/implant-based reconstruction requiring unilateral postmastectomy radiotherapy (PMRT), progressive radiation-induced fibrosis can lead to increasing nipple asymmetry with cosmetic dissatisfaction. Thus, PMRT may ultimately negate the intended positive cosmetic value of NSM compared with skin-sparing mastectomy (SSM). This study compares (1) surgical complications, (2) patient satisfaction, and (3) aesthetic outcomes between NSM versus SSM in bilateral implant-based reconstruction with unilateral PMRT. This retrospective matched cohort study included consecutive NSM patients with bilateral TE/implant breast reconstruction + unilateral PMRT matched 1:2 to SSM group. Patients completed PMRT and TE exchange to implants. Demographics, oncologic stage, comorbidities, and complications were collected. Patient satisfaction was evaluated by BREAST-Q. Aesthetic outcomes were assessed by blinded reviewers with a five-point Likert scale. Among 58 patients who underwent bilateral TE/implant reconstruction with unilateral PMRT, 17 NSM patients were matched to 41 SSM patients by age, body mass index, and comorbidities. No significant differences existed in overall surgical complications and individual BREAST-Q questionnaire scores between cohorts. However, aesthetic outcomes scores were higher in SSM compared with NSM. Although NSM is generally associated with superior cosmetic outcomes compared with SSM, it has far less impact in bilateral implant-based breast reconstruction with unilateral PMRT due to the negative postradiotherapy effect on nipple symmetry.

Unexpected histological appearance of breast implant associated fibrous pseudocapsules

BackgroundSkin flap necrosis is a common complication after mastectomy and breast reconstruction. It has been proven that nitroglycerin ointment, as a topical vasodilator, can decrease the rate of skin flap necrosis after mastectomy and breast reconstruction. However, nitroglycerin can cause several side effects, including headache, dizziness, and hypotension. The purpose of this study was to evaluate whether the application of a low dose of nitroglycerin ointment reduced the rate of skin flap necrosis in breast reconstruction after skin-sparing or nipple-sparing mastectomy.MethodsA total of 73 cases of breast reconstruction after nipple-sparing and skin-sparing mastectomy at our institution from March 2012 to January 2017 were retrospectively studied. Of these patients, 52 received nitroglycerin ointment (4.5 mg) application to the skin around the nipple-areolar complex from August 2015 to January 2017, while 21 received fusidic acid ointment from March 2012 to August 2015. The number of patients who experienced necrosis of the breast skin flap was counted in both groups.ResultsSkin flap necrosis developed in 2 (3.8%) patients who were treated with nitroglycerin ointment and 5 (23.8%) patients who did not receive nitroglycerin ointment treatment. Patients who did not receive nitroglycerin ointment treatment had a significantly higher risk of mastectomy skin flap necrosis than patients who did (odds ratio=7.81; 95% confidence interval, 1.38 to 44.23; P=0.02).ConclusionsLow-dose nitroglycerin ointment administration significantly decreased the rate of skin flap necrosis in patients who underwent breast reconstruction after skin-sparing or nipple-sparing mastectomy, without increasing the incidence of the side effects of nitroglycerin.

Background: Nipple-sparing mastectomy (NSM) is a standard for bilateral prophylactic surgeries. However for cancer treatment, the preservation of the nipple areolar complex (NAC) is still discussed because of suspected increase of local recurrence and surgical specific complications as nipple or mastectomy flap necrosis. The aim of the study was to investigate both the relapse risk associated with NSM for breast cancer and women's satisfaction with preservation of the NAC. Methods: We included retrospectively all patients who had skin-sparing mastectomy (SSM) or NSM from 2007 to 2012 for breast cancer or ductal carcinoma in situ (DCIS). We compared NSM and SSM group for oncological (overall survival (OS) and disease-free survival (DFS)) and surgical outcomes. Patients' satisfaction and quality of life has been evaluated by a specifically designed questionnaire, addressed by mail and inspired by the Breast-Q questionnaire with specific assessment of global esthetic result, harmony with the native breast and need for psychological support. Results: During the study, we operated 5600 patients for a breast cancer, among them, 152 had NSM (n=63 / 41.5%) or SSM (n=89 / 58.5%) with immediate implant breast reconstruction. Eighty-nine (58.6%) patients had DCIS, and the other had invasive disease (86.9% of T1). The mastectomy has been indicated for primary cancer (81%) or recurrence (19%). The two groups did not differ significantly according to histological type (p=0.10), grade (p=0.84), hormonal receptor (p=0.7), HER2 (p=1.00), Ki67 (p=0.75) or node metastases (p=0.64). Median follow-up was 42 (IQR: 18-58 ) months. No cancer-related death occurred during the study. Local recurrence rate was 1.7% (n=1) in NSM group and 0% in SSM group (p=0.35). The recurrence did not appear on the preserved nipple. Severe complication requiring surgery (Grade 3 of Clavien-Dindo classification) occurred in 9.9% of the cases. In the NSM group, one patient had complete NAC necrosis and three patients suffered partial necrosis. Severe skin-flap necrosis leading to implant removal was more frequent in the SSM group (SSM: 6.7% (n=6) ; NSM: 0% (n=0); p=0.042). One hundred and four (80%) patients answered the questionnaire. Satisfaction about the aspect of the NAC was higher in the NSM group compared to SSM with delayed reconstruction of the nipple (75% vs 59%, p=0.14). Patients with NSM needed less psychological support before (p=0.028) and immediately after surgery (p=0.14) than patients in the SSM group, which may suggest a better acceptation of the surgery in this group. Conclusion: NSM for breast cancer surgery was not associated with significant increase of local recurrence rate or surgical complications. Patient's satisfaction was high. Therefore, nipple-sparing mastectomy with immediate implant reconstruction can successfully and safely be performed for pre-invasive and small invasive breast cancer. Besides esthetic aspects, preserving the nipple may ease the acceptation of these radical surgeries. Citation Format: Regis C, Mesdag V, Tresch E, Chauvet MP, Boulanger L, Collinet P, Giard S. Is nipple-sparing mastectomy with implant reconstruction for breast cancer safe and worthwhile?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-09.

Nipple-sparing mastectomy (NSM) is more technically challenging than skin-sparing mastectomy (SSM) but offers quality-of-life and cosmetic advantages. However, surgeon physical symptoms related to NSM workload have not been documented. This was a prospective study using questionnaires to compare surgeon-reported physical symptoms before, during, and after NSM versus SSM. Surgeons also answered general questions about each mastectomy. Bilateral cases were performed simultaneously by two surgeons, who completed independent questionnaires. Questionnaires were completed after 82 SSMs and 44 NSMs. On a 0-10 scale, surgeons reported NSM was more physically demanding than SSM (7.0 vs. 4.5, p<0.001). Mean visualization was more difficult (5.7 vs. 3.2, p<0.001) and mean fatigue score was greater (5.6 vs. 3.1, p<0.001) after NSM than SSM. The mean increase in neck pain (on a 0-4 scale) was greater for NSM than SSM, both from before-to-during surgery (0.8 vs. 0.2, p=0.003) and before-to-after surgery (0.9 vs. 0.2, p=0.002). The mean increase in lower back pain was greater for NSM than SSM, both from before-to-during surgery (0.7 vs. 0.2, p=0.008) and before-to-after surgery (0.9 vs. 0.2, p=0.003). Surgeons reported that NSM was more mentally demanding (p<0.001), complex (p=0.01), and difficult (p<0.001) than SSM. Surgeons experienced greater physical symptoms, mental strain, and fatigue with NSM than SSM. This raises concern that mild but repetitive pain over the course of a breast surgeon's career may lead to repetitive stress injury.

A Novel Technique for Nipple-Sparing Mastectomy and Immediate Reconstruction in Patients with Macromastia

From January 2010 to September 2018, 253 breast reconstruction procedures were performed on 100 patients. The reverse expansion technique consists of autologous fat tissue transplantation requiring the combined use of a skin expander and of multiple lipofilling sessions. At the beginning of every session the breast expander was deflated by removing a saline volume similar to that of the fat to be injected. Overall, 56 breast reconstructions after skin-sparing mastectomy and 44 after nipple-sparing mastectomy were performed. An average of 661.5 cm3 of fat per session was harvested and an average of 305.3 cm3 per breast was injected. The average number of sessions to achieve breast reconstruction was 2.53. Only four complications after 253 procedures (1.5%) were reported: one donor site hemorrhage due to genetic lack of coagulation factors, and three surgical site infections. Considering the large number of positive factors such as a fast postoperative recovery, an easy learning curve, a lack of need of a specialized surgical team, a natural look of the breast shape, and the soft consistency of the grafted tissue, we believe this technique could be the first choice for autologous reconstruction after skin-sparing mastectomy and nipple-sparing mastectomy.

P337 The evaluation of safety of SSM and NSM with reconstruction after NAC for locally advanced BC

Introduction. A skin-sparing or nipple-sparing mastectomy is a surgical treatment that is increasingly used in the treatment of patients with breast cancer. More often women themselves decide or even ask to undergo this type of surgery. In our paper, we present the issue of combined treatment of 62 patients after nipple-sparing or skin-sparing mastectomy with a positive sentinel lymph node. Realisation of this type of surgery has further consequences in adjuvant treatment policies. Material and methods. The group of 62 previously untreated women with positive sentinel lymph nodes took part in this analysis. The individual plan of treatment was established for every patient by the multidisciplinary team according to the rules of the breast cancer unit. All patients were treated in the Holycross Cancer Centre in Kielce (in 2015–2018). Results. The early results show that proper qualification and realisation of oncological treatment is safe and effective. Severe complications appeared rarely. Conclusions. Skin-sparing or nipple-sparing mastectomy is a method of surgical treatment that is increasingly used in the treatment of patients with breast cancer. It should be remembered that the qualification for this type of procedure should be careful, and adjuvant treatment should be rationally planned. Our experience shows that it is an effective and safe method.