Nipple-areola Complex Necrosis Research Articles

Indocyanine Green Angiography-Assisted Pure Hemi-Periareolar Incision Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction.

Although pure hemi-periareolar incisions for mastectomy can prevent visible scarring, nipple-areolar complex (NAC) necrosis is a potential risk. Superficial-arterial inflow of the NAC can be evaluated by indocyanine green angiography (ICG-A). This study evaluated the impact of ICG-A assisted periareolar incision on NAC necrosis during nipple-sparing mastectomy (NSM) and direct-to-implant (DTI) breast reconstruction. Between December 2018 and November 2021, lateral hemi-periareolar incisions for NSM were routine. After that time, ICG-A-assisted hemi-periareolar incisions were performed between December 2021 and Sept. 2023. The location of the main arterial inflow was evaluated during preoperative ICG-A and the periareolar incision was planned to avoid disruption. NAC necrosis in the ICG-A-assisted and blind-incision groups was compared using univariate and multivariate analyses. A total of 202 breasts were analyzed including 80 breasts from 75 patients in the ICG-A-assisted group and 122 breasts from 115 patients in the blind-incision group. On preoperative ICG-A, superficial-arterial inflow was observed in 67 of 80 (83.75%) breasts. Perfusion of the nipple without superficial-arterial inflow (base-perfusion pattern) was observed in 13 breasts (16.25%). The main arterial inflow was most common in the upper-medial direction at the areolar margins (65.67%). The full-thickness NAC necrosis rate in the ICG-A-assisted incision group was significantly lower than that in the blind-incision group (2.5% vs. 13.1%, p = 0.010). Multivariate analysis demonstrated that ICG-A-assisted incisions significantly reduced the risk of NAC necrosis (odds 0.155, p = 0.030). ICG-A-assisted pure hemi-periareolar incisions reduced NAC necrosis in DTI breast reconstructions.

Staged Nipple Delay Procedure Expands Candidacy for Nipple-Sparing Mastectomy.

Nipple delay (ND) is a staged procedure that improves nipple-areolar complex (NAC) viability in nipple-sparing mastectomy (NSM) patients who are high-risk for NAC or skin-flap necrosis. This study compared postoperative outcomes and risk factors between patients treated with ND-NSM and NSM alone. Patient demographics, risk factors for NAC or skin-flap necrosis, tumor characteristics, and operative outcomes were compared between ND-NSM and NSM groups from 2009 to 2023. Univariate and multivariate analyses were performed to identify significant variables associated with NAC or skin-flap necrosis. Overall, 71 ND-NSM patients and 537 NSM patients were compared. ND-NSM patients had larger breasts (p<0.01), body mass index ≥ 30 (p=0.01), prior breast/chest wall radiation (XRT) [p<0.01], prior breast operations (p<0.01), less axillary surgery (p<0.01), more autologous tissue reconstruction over implant-based reconstruction compared with NSM patients (p=0.02), and more prophylaxis (p<0.01). There were no statistically significant differences between groups in regard to infection, skin-flap necrosis, NAC necrosis, seromas, and hematomas. No patients in the ND-NSM group had NAC necrosis and 1 patient had skin-flap necrosis, compared with 17 and 13 patients in the NSM group, respectively (p=0.24). On univariate analysis, prior XRT was associated with increased risk for skin-flap necrosis (p=0.02). Multivariate analysis showed XRT was associated with skin-flap necrosis (p=0.02) and any necrosis (p=0.01). Breast size was associated with NAC or skin-flap necrosis (p=0.04). Larger breasts and XRT were risk factors for NAC or skin-flap necrosis; however, despite having more risk factors, ND-NSM patients had very low rates of necrosis. Notably, no nipples were lost. A shared decision should be made with patients regarding the risks and benefits of ND-NSM.

Minimal Access vs Conventional Nipple-Sparing Mastectomy

While nipple-sparing mastectomy (NSM) for breast cancer was only performed using the open method in the past, its frequency using endoscopic and robotic surgical instruments has been increasing rapidly. However, there are limited studies regarding postoperative complications and the benefits and drawbacks of minimal access NSM (M-NSM) compared with conventional NSM (C-NSM). To examine the differences in postoperative complications between C-NSM and M-NSM. This was a retrospective multicenter cohort study enrolling 1583 female patients aged 19 years and older with breast cancer who underwent NSM at 21 university hospitals in Korea between January 2018 and December 2020. Those with mastectomy without preserving the nipple-areolar complex (NAC), clinical or pathological malignancy in the NAC, inflammatory breast cancer, breast cancer infiltrating the chest wall or skin, metastatic breast cancer, or insufficient medical records were excluded. Data were analyzed from November 2021 to March 2024. M-NSM or C-NSM. Clinicopathological factors and postoperative complications within 3 months of surgery were assessed. Statistical analyses, including logistic regression, were used to identify the factors associated with complications. There were 1356 individuals (mean [SD] age, 45.47 [8.56] years) undergoing C-NSM and 227 (mean [SD] age, 45.41 [7.99] years) undergoing M-NSM (35 endoscopy assisted and 192 robot assisted). There was no significant difference between the 2 groups regarding short- and long-term postoperative complications (<30 days: C-NSM, 465 of 1356 [34.29%] vs M-NSM, 73 of 227 [32.16%]; P = .53; <90 days: C-NSM, 525 of 1356 [38.72%] vs M-NSM, 73 of 227 [32.16%]; P = .06). Nipple-areolar complex necrosis was more common in the long term after C-NSM than M-NSM (C-NSM, 91 of 1356 [6.71%] vs M-NSM, 5 of 227 [2.20%]; P = .04). Wound infection occurred more frequently after M-NSM (C-NSM, 58 of 1356 [4.28%] vs M-NSM, 18 of 227 [7.93%]; P = .03). Postoperative seroma occurred more frequently after C-NSM (C-NSM, 193 of 1356 [14.23%] vs M-NSM, 21 of 227 [9.25%]; P = .04). Mild or severe breast ptosis was a significant risk factor for nipple or areolar necrosis (odds ratio [OR], 4.75; 95% CI, 1.66-13.60; P = .004 and OR, 8.78; 95% CI, 1.88-41.02; P = .006, respectively). Conversely, use of a midaxillary, anterior axillary, or axillary incision was associated with a lower risk of necrosis (OR for other incisions, 32.72; 95% CI, 2.11-508.36; P = .01). Necrosis occurred significantly less often in direct-to-implant breast reconstruction compared to other breast reconstructions (OR, 2.85; 95% CI, 1.11-7.34; P = .03). The similar complication rates between C-NSM and M-NSM demonstrates that both methods were equally safe, allowing the choice to be guided by patient preferences and specific needs.

Secondary reduction mammaplasty techniques and outcomes: Cleveland Clinic experience

BackgroundInformation on optimal techniques and outcomes following secondary reduction mammaplasty remains sparse with only 280 patient cases reported in the literature to date. Methods7,179 medical charts of patients who underwent non-oncological breast reduction at the Cleveland Clinic Health System from January 2001 to October 2023 were screened to identify whether the procedure was a secondary reduction. Patient charts were then reviewed to extract demographic, surgical, and outcome data. Patients were also contacted through the electronic medical record to fill out the BREAST-Q V2 questionnaire about post-operative satisfaction. Surgical techniques and satisfaction were compared for patients with complications versus those without. ResultsOne hundred and twenty-two (1.7%) patients underwent secondary breast reduction. An inferior pedicle was the most used for both primary (n=59, 48.4%) and secondary (n=64, 52.5%) surgeries. The primary pedicle was re-created in 62 of the 84 (73.8%) re-reductions where a primary pedicle was known. A total of 15 patients (12.3%) completed the BREAST-Q questionnaire. BMI was significantly and negatively associated with satisfaction with outcome (R=-0.66, p=0.01), sexual wellbeing (R=-0.58, p=0.04), and physical wellbeing (R=-0.69, p=0.006). No patients experienced nipple-areolar-complex (NAC) necrosis following secondary reduction. However, 21 (17.2%) of patients experienced complications or breast fat necrosis following re-reduction. Unmatched secondary pedicles showed a trend towards higher complication rates than matched secondary pedicles (31.3% vs. 12.9%, p=0.051). ConclusionWhen known, the primary pedicle can be safely used for secondary reduction mammaplasty with minimal risk of NAC necrosis or complication.

Robotic nipple sparing mastectomy and immediate breast reconstruction: significant attempts with the latissimus dorsi muscle without island flap.

This study presents preliminary results of robot-assisted nipple-sparing immediate breast reconstruction (R-NSMIBR) with gel implant combined with latissimus dorsi muscle flap without island flap and validation of the safety and utility of this novel surgical modality. Records pertinent to R-NSMIBR with gel implants combined with latissimus dorsi muscle flap surgery for breast reconstruction between September 2022 and May 2023 were examined. A total of 13 patients who underwent R-NSMIBR were analyzed, nine of which were performed without skin island. We divided the patients with and without skin islands into two groups and recorded the operation time and bleeding respectively. The mean total operative time for R-NSMIBR was 436.5±56.88 minutes and 355.75±69.68 minutes. As experience in learning increased, time required to create the operating space and position the robotic arm decreased significantly. Not creating an island of skin also saves a great deal of surgical time. Average total blood loss was 37.5±6.45 mL and 26.25±7.5 mL. No cases of nipple-areolar complex necrosis or perioperative complications or no local recurrences were reported. There were no local recurrences or deaths that occurred during a mean follow-up period of 3±1 months. All the patients expressed satisfaction with the aesthetic outcome following surgery. There were no significant differences between two groups. This surgical method shows promise for future promotion in the field.

Noninvasive Real-Time Assessment of Nipple-Areola Complex Perfusion Using Laser Speckle Contrast Imaging in Direct-to-Implant Breast Reconstruction.

Nipple-areola complex (NAC) necrosis is a major complication for breast reconstruction after nipple-sparing mastectomy. Although intraoperative indocyanine green angiography helps to assess the viability of tissue, the imaging could be conservative which may lead to aggressive resection. The plastic surgeons are eager to know the perfusion changes of NAC throughout the perioperative period. In this prospective cohort study, the authors enrolled patients who underwent NSM and immediate direct-to-implant breast reconstruction. All patients underwent laser speckle contrast imaging before surgery, immediately after mastectomy, after implant placement, and 24h and 72h after surgery. A total of 94 breasts were analyzed, including 64 breasts healed with viable NAC and 30 breasts with NAC necrosis. In viable NACs, the average blood supply decreased to 56% after NSM and 42% after reconstruction, then recovered to 68% and 80% at 24-h and 72-h post-operation. In necrotic NACs, the average blood supply decreased to 33% after NSM and 24% after reconstruction, and partial perfusion recovery was also recorded at 24-h (31%) and 72-h (37%) post-operation. The cutoff value for predicting NAC viability is 40% after NSM and 25% after implant placement. The study quantified the NAC perfusion changes during the perioperative period. NAC perfusion decreased significantly after NSM and would be the lowest after the end of breast reconstruction. Viable NACs displayed more perfusion during the operation and showed significant nipple revascularization after breast reconstruction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A New Convenient Incision Model of the Nipple-Sparing Mastectomy: Lateralized Parabolic Multiplanar Incision.

In this study, a lateralized parabolic multiplanar incision was defined. It was aimed to reduce necrosis in the nipple-areola complex (NAC) and, in the long run, to prevent the scar from pulling the areola laterally by maintaining healthy skin tissue between the scar and the areola and preserving the natural round appearance of the areola. Moreover, we purposed the scar not to be visible from the anterior view. The study included 243 patients who underwent nipple-sparing mastectomy and immediate implant-based breast reconstruction. The incision was made 4-5 cm away from the lateral border of the NAC. The incision was completed after passing the anterior axillary line by drawing a parabolic curve in superolateral axis. The mean follow-up period was 24.6 months, and the mean age of the patients was 42.3 years. Full-thickness necrosis of the NAC occurred in 3.6% of breasts. In long-term follow-ups, the incision scar measured an average length of 8.6 cm. None of the patients had lateral displacement of the NAC. The NAC preserved its round appearance, except for 12 breasts that had full-thickness NAC necrosis. Ten breasts had an unnatural breast appearance. The lateralized parabolic multiplanar incision is an ideal incision model for nipple-sparing mastectomy, as it allows for the exposure and reconstruction of all breast quadrants. We maintain areolar circulation; there are no visible scars when viewed anteriorly. Furthermore, it prevents lateral displacement of the NAC, ensuring that the natural round form of the NAC is not distorted. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy.

Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

Combination of Superior and Superomedial Pedicle Techniques in Reduction Mammaplasty: A Modified Approach to Increase Upper Pole Fullness.

Creation of the upper pole fullness is one of the basic goals in reduction mammaplasty. The superior pedicle (S-P) technique brings extra tissue to the upper pole, but folding of a long pedicle can compromise circulation of the nipple-areola complex (NAC). Although the pedicle is not folded in superomedial pedicle (SM-P) technique, it has disadvantage of not bringing extra tissue to the upper pole. We designed a new approach by combining the advantages of S-P and SM-P techniques. Thereby, we aimed to increase upper pole fullness in SM-P or superolateral pedicle (SL-P) mammaplasty. We operated 20 female patients (study group) with the modified SM-P/SL-P technique for breast reduction between 2010 and 2022. Preoperatively, mean sternal notch-nipple distance was 32.6 ± 2.5cm. The upper pole fullness was created by using a superiorly based glandular flap, while the SM-P (17 patients) or SL-P (three patients) was used to carry the NAC. We assessed the success rate of the upper pole fullness, compared with two control groups of 40 patients who underwent conventional SM-P mammaplasty (control group I: 20 patients) and who underwent conventional S-P mammaplasty (control group II: 20 patients). Two plastic surgeons, who do not know which technique was used, assessed before and after photographs of 60 patients regarding success rate of upper pole fullness. To evaluate the success rate, the degree of the difference in the upper pole fullness between before and after photographs has been scored 1-10 for each patient. Below 5 was considered as no difference (unsuccessful), 5-7 as moderate difference (average), 8-10 as significant difference (successful). Photographs of the patients had been taken from five different angles: frontal, right and left oblique views, and right and left sides. Out of 10, mean score was 8.2 ± 1.2 in study group, 7.1 ± 1.8 in control group I, 8.2 ± 1.5 in control group II. Postoperatively, no major complications were observed, such as glandular necrosis, total NAC necrosis, partial (> 50%) NAC necrosis, skin necrosis, or poor NAC sensitivity in none of 60 patients. By using this modification, it is possible to increase upper pole fullness in SM-P/SL-P mammaplasty. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25weeks between first and second stage procedures.

Pedicle Selection and Design in Reduction Mammaplasty: The Role of Preoperative Fluorescence Imaging.

Breast reduction has a wide selection of pedicles but often relies on the surgeon's preference and experience. Necrosis of the nipple-areola complex (NAC) is a catastrophic complication of breast reduction surgery. To solve the above problem objectively, we applied fluorescence imaging technology to the pedicle selection and design of breast reduction surgery for the first time, so that the dominant vessels of the NAC were included in the designed pedicle. We retrospectively enrolled 120 patients with breast reduction (a total of 239 breasts). We compared 60 patients who underwent breast reduction without fluorescence imaging for pedicle selection (Group A) with 60 patients who underwent pedicle selection with fluorescence imaging (Group B). The NAC blood supply was monitored after the operation. In this study, 60 Group A cases (119 breasts) and 60 Group B cases (120 breasts) were analyzed. There were no statistically significant differences in patient demographic data or intraoperative resection weights. There were 7 cases of NAC necrosis in Group A (1 case of complete necrosis and 6 cases of partial necrosis), while no NAC necrosis occurred in Group B. There was a significant difference in the rate of NAC necrosis between the 2 groups. Preoperative fluorescence imaging can guide the selection and design of breast reduction, significantly reducing postoperative NAC blood supply obstacles and necrosis.

Preoperative visualization of mammary artery for breast reduction surgery based on computed tomography angiography

BackgroundMacromastia, characterized by an increase in breast size, poses challenges such as elevated body burden and chest oppression, potentially leading to cardiac and pulmonary overload. A crucial aspect of addressing these challenges involves preoperative planning, aiming to acquire detailed images and a 3D model of the internal mammary artery with minimal radiation exposure.PurposeThis study aimed to explore the clinical significance of computed tomography angiography (CTA) of the mammary artery in preoperative planning for breast reduction surgery.MethodsRetrospective analysis was conducted on CT images from 60 patients scheduled for breast reduction surgery in the plastic surgery department. These images were processed using a post-processing workstation to extract internal mammary arteries for subsequent 3D modeling. Radiologists and plastic surgeons collaborated to perform preoperative planning based on the 3D model and associated measurement parameters. Subsequent follow-up examinations occurred 4 to 9 months post-surgery, evaluating necrosis rates and complications of the nipple-areola complex (NAC).ResultsA total of 206 blood vessels were reconstructed and extracted in 60 patients, including 156 main arteries and 50 arterioles. There were no instance of NAC necrosis, complications, or infections in the 4–9 months follow-up period.ConclusionsPreoperative Mammary artery CTA emerged as a valuable tool, facilitating a comprehensive understanding of the internal mammary arteries and the primary blood supply in the NAC region. This approach effectively minimizes the risk of NAC supply artery injury during surgery, thereby preserving the functionality of the nipple and areola.

Effects ofGynecomastia Surgery onReadiness andReturn to Duty inan Active Duty Military Population.

Simple mastectomies are routinely performed in the military health care system as gynecomastia can cause significant pain and discomfort when wearing body armor. Postoperative recovery negatively impacts personnel readiness. In this study, we sought to study time to return to duty in active duty service members who undergo surgery for gynecomastia. We conducted a single-center retrospective review of active duty patients undergoing a surgical operation for gynecomastia from July 2020-June 2022. A total of 96 patients were included. Our primary outcome of interest was time from surgery to return to duty. A multivariate analysis was performed to assess for factors independently associated with surgical complications including patient demographics and operative techniques. The median number of days to return to duty after surgery was 28 days (IQR 13-37). The median loss of duty days because of gynecomastia without surgery was 19 days (IQR 10-21), which was different on the Mann-Whitney U test. Surgical complications were observed in 19 patients (19.7%) with the most common complications being seroma (11), hematoma (4), nipple-areolar complex necrosis (2), and infection (2). Patients with a complication have significantly more time to return to duty (28 vs. 49 days, P < .001). Risk factors associated with an increased risk of complication include ranks E1-E4, behavioral health diagnosis, "open" vs. "combined" technique with liposuction, length of operation greater than 58 minutes, and excised breast mass greater than 17.9 g. Gynecomastia surgery is associated with a detriment to personnel readiness. Surgery should be reserved for patients with severe symptoms that prevent the performance of daily duties. Furthermore, factors associated with an increased risk for complications include ranks E1-E5, behavioral health diagnosis, length of operation >58 minutes, and excised breast mass >17.9 g. The operating surgeon should be mindful of these factors.

Inframammary versus Periareolar Incision: A Comparison of Early Complications in Nipple-sparing Mastectomy.

Nipple-sparing mastectomy (NSM), either used therapeutically or prophylactically, may yield more complications than conventional mastectomy. The incision may affect aesthetic outcome and complication rates, with periareolar incisions being associated with nipple-areolar complex (NAC) necrosis. Early complications were compared between NSM performed in 2015-2022 using inframammary fold (IMF) or periareolar incisions. Overall, 180 procedures in 152 patients (bilateral NSM = 28) were included (IMF = 104; periareolar = 76). Mean age (47 versus 43.9 years; P < 0.038), mastectomy weight (312.7 versus 246.8 grams; P < 0.001), implant volume (447.5 versus 409.0 mL; P = 0.002), and use of tissue expanders (68.4% versus 50.0%; P = 0.013) were all greater with periareolar incisions. Prepectoral reconstruction was more common with IMF (18.3% versus 3.9%; P = 0.004). Forty-three complications (23.9%) were recorded (periareolar n = 27, 35%; IMF n = 16, 15.3%; P = 0.0002). NAC necrosis accounted for 17 complications (22.4%) in the periareolar group versus nine (8.5%) in the IMF group (P = 0.002). Necrosis was predominantly moderate (n = 6, 8.3% versus n = 1, 1.0%, respectively) (P = 0.014). Unadjusted odds ratios (OR) for complications [3.05; 95% confidence interval (CI): 1.27-7.26] and necrosis (3.04; 95% CI: 1.27-7.27) were higher in the periareolar group. In the multivariate analysis, necrosis was associated with periareolar incisions [adjusted odds ratio (aOR): 2.92; 95% CI: 1.14-7.44]. Prepectoral reconstruction was associated with IMF incisions (aOR: 25.51; 95% CI: 3.53-184.23; P = 0.001) and with body mass index of more than 25-30 (aOR: 37.09; 95% CI: 5.95-231.10; P < 0.001). Therapeutic mastectomies (aOR: 68.56; 95% CI: 2.50-188.36; P = 0.012) and tissue expanders (aOR: 18.36; 95% CI: 1.89-178.44; P = 0.026) were associated with seromas. Both incisions are viable options; however, the risk of NAC necrosis increased with the periareolar approach. Further research is required.

Single-port three-dimensional (3D) endoscopic-assisted breast surgery—preliminary results and patient-reported satisfaction in 145 breast cancer and gynecomastia cases

BackgroundMinimal-accessed (robotic and endoscopic) breast cancer surgery is increasingly performed due to better cosmetic results and acceptable oncological outcomes. This study aims to demonstrate the clinical safety and patient-reported cosmetic satisfaction of single-port three-dimensional endoscopic-assisted breast surgery (S-P 3D EABS), which is our new endoscopic surgical innovation, in both malignant and benign breast conditions.MethodsPatients who underwent S-P 3D EABS from 1 August 2018 to 31 July 2022 in a single institution were enrolled. Clinical outcomes of this procedure were retrospectively reviewed, and the patient-reported cosmetic satisfaction was evaluated by a questionnaire and reported herein.ResultsDuring the study period, 145 patients underwent 164 procedures of S-P 3D EABS. One hundred fifty (91.5%) procedures were endoscopic-assisted nipple-sparing mastectomy (S-P 3D E-NSM; 117 therapeutic procedures for breast cancer, 13 prophylactic mastectomies, 20 procedures for gynecomastia). Fourteen (8.5%) procedures of endoscopic-assisted breast-conserving surgery (S-P 3D E-BCS) were performed (12 S-P 3D E-BCS, 2 S-P 3D E-BCS with 3D videoscope-assisted partial breast reconstruction, which was 1 case of latissimus dorsi flap and 1 case of omental flap). The mean operative time was 245 ± 110 min in S-P 3D E-NSM and 260 ± 142 min in S-P 3D E-BCS. The mean intraoperative blood loss was 49.7 ± 46.9 ml in S-P 3D E-NSM and 32.8 ± 17.5 ml in S-P 3D E-BCS. Subnipple biopsy showed positive malignancy in 3 (2.6%) S-P 3D E-NSM patients. None of the S-P 3D E-BCS patients found margin involvement; however, 3 (2.6%) reported margin involvement in S-P 3D E-NSM patients. Thirty-two complications were found (24.6%): 7 (5.3%) transient nipple-areolar complex (NAC) ischemia, 7 (5.3%) partial NAC necrosis, 1 (0.7%) total NAC necrosis, and 1 (0.7%) implant loss. During the mean follow-up time of 34 months, there were 2 (1.5%) patients with locoregional recurrence, 9 (6.9%) distant metastasis, and 2 (1.5%) mortality. 78.6% (77/98) of patients answering the cosmetic-evaluated questionnaire reported good and excellent overall satisfaction.ConclusionsS-P 3D EABS is a novel surgical innovation, which is able to perform safely in either malignant or benign breast conditions and offer promising cosmetic results.

Superomedial-Posterior Pedicle-Based Reduction Mammaplasty: Evaluation of Effectiveness and BREAST-Q Outcomes of a Rapid and Safer Technique

IntroductionBreast hypertrophy, a common pathological condition, often requires surgical intervention to alleviate musculoskeletal pain and improve patients’ quality of life. Various techniques have been developed for breast reduction, each with its own advantages and complications. The primary aim of this study is to evaluate the efficacy, safety, and patient-reported outcomes of the authors technique: the Superomedial-Posterior Pedicle-Based Reduction Mammaplasty.Material and MethodsA prospective study was conducted on 912 patients who underwent breast reduction surgery between November 2012 and July 2020. The surgical technique involved preserving all glandular tissue from the areola to the pectoralis major muscle using the superomedial-posterior pedicle. The patients’ demographic data, operative details, complications, breast-related quality of life (measured using the Breast-Q questionnaire), and nipple–areola complex sensitivity were analyzed.ResultsThe average operative time was 62.12 ± 10.3 minutes. Complications included minor wound dehiscence (4.05%) and hematoma (1.2%), with no cases of nipple–areola complex necrosis. Nipple–areola sensitivity was fully restored in all patients at the 2-year follow-up. Patient satisfaction with the procedure was high with a statistically significant difference observed between pre- and postoperative scores (p < 0.001) of the Breast-Q questionnaire.ConclusionAuthors technique offers reliable vascularization and innervation of the nipple–areola complex and achieves satisfactory aesthetic outcomes. It is associated with shorter operative times compared to other techniques reported in the literature. The Superomedial-Posterior Pedicle-Based Reduction Mammaplasty represents a safe and effective method for breast reduction surgery, providing significant benefits to patients with breast hypertrophy.Level of Evidence IThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Predicting Complications in Breast Reconstruction: Development and Prospective Validation of a Machine Learning Model.

Necrosis of the nipple-areolar complex (NAC) is the Achilles heel of nipple-sparing mastectomy (NSM), and it can be difficult to assess which patients are at risk of this complication (Ann Surg Oncol 2014;21(1):100-106). To develop and validate a model that accurately predicts NAC necrosis in a prospective cohort. Data were collected from a retrospectively reviewed cohort of patients who underwent NSM and immediate breast reconstruction between January 2015 and July 2019 at our institution, a high -volume, tertiary academic center. Preoperative clinical characteristics, operative variables, and postoperative complications were collected and linked to NAC outcomes. These results were utilized to train a random-forest classification model to predict necrosis. Our model was then validated in a prospective cohort of patients undergoing NSM with immediate breast reconstruction between June 2020 and June 2021. Model predictions of NAC necrosis in the prospective cohort achieved an accuracy of 97% (95% confidence interval [CI], 0.89-0.99; P = 0.009). This was consistent with the accuracy of predictions in the retrospective cohort (0.97; 95% CI, 0.95-0.99). A high degree of specificity (0.98; 95% CI, 0.90-1.0) and negative predictive value (0.98; 95% CI, 0.90-1.0) were also achieved prospectively. Implant weight was the most predictive of increased risk, with weights greater than 400 g most strongly associated with NAC ischemia. Our machine learning model prospectively predicted cases of NAC necrosis with a high degree of accuracy. An important predictor was implant weight, a modifiable risk factor that could be adjusted to mitigate the risk of NAC necrosis and associated postoperative complications.

Single axillary incision reverse-order endoscopic nipple/skin-sparing mastectomy followed by subpectoral implant-based breast reconstruction: Technique, clinical outcomes, and aesthetic results from 88 preliminary procedures

BackgroundSingle axillary incision reverse-order endoscopic nipple-sparing mastectomy overcomes the limitations of conventional endoscopic nipple-sparing mastectomy application. We introduce this technique and report the preliminary results of this study. MethodsPatients who received single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy from May 2020 to May 2022 were enrolled from a single institution. Data were analyzed to evaluate the safety and effectiveness of this technique. Patient-reported and surgeon-reported cosmetic outcomes were collected. ResultsIn total, 68 patients who underwent 88 single axillary incision reverse-order endoscopic nipple-/skin-sparing mastectomy combined with subpectoral implant-based breast reconstruction were enrolled in the current study. The overall complication rate was 10.3%. In total, 2.9% of patients suffered from major complications, and 5 (7.4%) experienced minor complications. Only 1 patient experienced partial nipple-areola complex necrosis. During a median follow-up time of 24 months, the locoregional recurrence and distant metastasis rate was both 1.6%. In the surgeon-reported cosmetic results, 92.1% of patients achieved good or excellent results. The mean SCAR-Q scores were 82.07 ± 8.86, and 85.3% evaluated their breasts as good or excellent. The mean overall cost was 5,670.4 ± 1,351.3 USD. The total mean operation time and maturity-stage mean operation time were 234.3 ± 80.4 and 172.55 ± 41.29 min, respectively. According to cumulative sum plot analysis, approximately 18 cases were needed for surgeons to decrease their operation time significantly and complication rate. ConclusionSingle axillary incision reverse-order endoscopic nipple-sparing mastectomy is a safe, less expensive, and efficient surgical technique with reliable intermediate-term oncologic safety. For suitable candidates, the technique with subpectoral implant-based breast reconstruction can provide a good cosmetic outcome.

Intraoperative Examination of Retro-Areolar Margin is not Routinely Necessary During Nipple-Sparing Mastectomy for Cancer.

Intraoperative examination of retro-areolar margin (IERM) often is used during nipple-sparing mastectomy (NSM) for cancer, but there is no robust data regarding its real advantage. Consecutive patients undergoing NSM for cancer with omission of IERM according to institutional protocols from 2016 to 2021 were retrospectively analyzed. The decision to maintain or remove the Nipple-Areola Complex (NAC) after definitive pathology was taken at the multidisciplinary meeting. Among 162 women operated in the study period, the presence of neoplastic cells within 2mm from the inked retroareolar margin (RAM) was detected at permanent pathology in 17 cases (10.5%). Nipple-Areola-Complex (NAC) was removed postoperatively in five patients (3%) for margins <1mm, the other 12 were observed, whereas postoperative NAC necrosis required surgical removal in additional five cases (3%). The NAC was thus preserved in 152 of 162 patients (94%). At multivariate analysis, RAM ≤2mm was associated with radiological tumor-to-nipple distance less than or equal to 1cm (p = 0.04) and Ki67 label index ≥ 20 (p = 0.04), whereas multifocality/multicentricity showed a trend towards significance (p = 0.07). At a median follow-up of 46 months, five locoregional relapses occurred (3%), only one of them involving the NAC (0, 6%). Locoregional relapse and overall survival for patients with RAM > or < 2mm were not different. IERM is not routinely necessary during NSM for cancer, because its omission is associated with a very low return to the operating room, it is oncologically safe, and associated pitfalls are avoided. Further studies are necessary to confirm these findings.

The Infero-Central Mound Reduction Mammoplasty: A Single Surgeon, 20-year Experience.

Reduction mammoplasty (RM) remains one of the most common plastic surgeries worldwide. Many different techniques have been described in the literature, each with its advantages and limitations. Nipple-areolar complex necrosis remains a daunting complication, regardless of the chosen surgical approach. We describe the senior author's (HYK) unique reduction mammoplasty technique, employing the infero-central (IC) pedicle throughout the last two decades. A retrospective chart review of 520 patients undergoing breast reduction was performed. After exclusion criteria, 360 were included in the study. These patients underwent RM with the IC technique, with stabilization of the breast mound and plication of the inferior pole dermis to prevent bottoming out. Demographics, operative data, and complications were recorded. Pre- and postoperative photographs were evaluated by a specialists' panel. The BREAST-Q questionnaire was utilized to assess satisfaction rates. BREAST-Q questionnaire-satisfaction with breast score was 84.19, and outcome score was 91.67. Aesthetic outcome evaluation, reviewed by four plastic surgeons, yielded a high score in all parameters (1.64-2; range 0-2). On a per-breast basis for all patients, the following complications were analyzed: dehiscence (3.61%), infection (2.22%), hematoma (1.66%), superficial wound healing problems (1.38%), seroma (0.83%), skin flap ischemia (1.52%), hypertrophic scar (1.38%), fat necrosis (0.97%), and partial nipple ischemia (0.27%). Infero-central mound technique can be applied to breast reductions of nearly all sizes, allowing for consistently satisfactory aesthetic outcomes for most patients. Due to robust vascularity of the pedicle, complication rates are kept at a minimum. IC mound technique is an essential tool in the plastic surgeon's armamentarium. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .