Delayed Nipple-Sparing Modified Subcutaneous Mastectomy: Rationale and Technique

Beniamino Palmieri,Simone Grappolini,George Baitchev,Giorgia Benuzzi,Alberto Costa

doi:10.1111/j.1075-122x.2005.21520.x

Beniamino Palmieri, Simone Grappolini + Show 3 more

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https://doi.org/10.1111/j.1075-122x.2005.21520.x

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Abstract

The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective.

Highlights

The inheritable breast cancer recently detectable by evidence of the BRCA-1/BRCA-2 gene mutation, lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ are currently faced on a preventive basis with selective screening and follow-up, chemoprevention, and/or prophylactic mastectomy [1,2,3,4]
Our study addresses the hypothesis of a new radical approach to subcutaneous mastectomy while retaining the integrity of the nipple-areola complex (NAC), without leaving any gland stalk or parenchyma underneath, and obtaining complete clearance of the breast tissue
The procedure was divided into two different phases: NAC vascular autonomization on an outpatient basis using local tumescent anesthesia with laparoscopic instrumentation; and delayed nipple-sparing modified subcutaneous mastectomy using general anesthesia with tumescent technique plus subpectoralis textured silicone breast implant

Summary

Introduction

The inheritable breast cancer recently detectable by evidence of the BRCA-1/BRCA-2 gene mutation, lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ are currently faced on a preventive basis with selective screening and follow-up, chemoprevention, and/or prophylactic mastectomy [1,2,3,4]. The surgical options of simple mastectomy and subcutaneous mastectomy— the former excising the nipple-areola complex (NAC) together with the gland, the latter leaving intact the NAC— provides 95–99% and 90–95% breast tissue removal, respectively, and being inadequate as to oncologic radicality [5]. Our study addresses the hypothesis of a new radical approach to subcutaneous mastectomy while retaining the integrity of the NAC, without leaving any gland stalk or parenchyma underneath, and obtaining complete clearance of the breast tissue. Primary reconstruction with subpectoralis prosthesis or two-stage replacement with an expander are the surgical options to complete the procedure in order to achieve satisfactory cosmetic results. This procedure addresses both cancer prophylaxis and stage I cancer treatment

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