Preservation Of Nipple-areola Complex Research Articles

A Nomogram Based on Conventional and Contrast-Enhanced Ultrasound for Pre-operative Prediction of Nipple-Areola Complex Involvement in Breast Cancer: A Prospective Study.

Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is essential for identifying eligible patients for a nipple-sparing mastectomy. This study was aimed at developing a pre-operative nomogram for NAC involvement in breast cancer using conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS). All patients with primary breast cancer confirmed by pre-operative biopsy underwent US and CEUS examinations. Post-operative pathology was used as the gold standard in assessing NAC involvement. Lasso regression was used to select the predictors most associated with NAC involvement. A nomogram was constructed to calculate the diagnostic efficacy. The data were internally verified with 500 bootstrapped replications, and a calibration curve was generated to validate the predictive capability. Seventy-six patients with primary breast cancer were included in this study, which included 16 patients (21.1%) with NAC involvement and 60 patients (78.9%) without NAC involvement. Among the 23 features of US and CEUS, Lasso regression selected one US feature and two CEUS features, namely, ductal echo extending from the lesion, ductal enhancement extending to the nipple and focal nipple enhancement. A nomogram was constructed, and the results revealed that the area under the curve, sensitivity, specificity and accuracy were 0.891, 81.3%, 86.7% and 85.5%, respectively. The calibration curve exhibited good consistency between the predicted probability and the actual probability. The nomogram developed based on US and CEUS had good performance in predicting NAC involvement in breast cancer before surgery, which may facilitate the selection of suitable patients for NAC preservation with greater oncological safety.

Nipple Sparing Goldilocks Mastectomy, A New Modification of the Original Technique.

Although Goldilocks mastectomy offers good aesthetic outcomes. Removal of the nipple-areolar complex (NAC) often has a negative psychological impact. The objective of this study was to assess the feasibility and esthetic outcome of this technique with salvage of the NAC using a dermal pedicle. The study included female patients suffering from breast carcinoma with large and or ptotic breast. Patients were offered Goldilocks mastectomy. Those who were unfit for anesthesia, those with locally advanced or metastatic disease or those refusing the procedure were excluded. Fifteen female patients (18 breasts) with a mean age of 51.6 years underwent Goldilocks breast reconstruction with a trial of NAC preservation. The mean body mass index was 39.1 kg/m2. More than half (56%) were cup C, while 44% were cup D. Seven cases (46.7%) showed grade II ptosis and 8 (53.3%) were grade III. The mean operative time was 168 minutes (range 130-240 minutes). NAC ischemic changes were noted in five cases; two (11%) were partial while three (17%) were total. Two cases (11%) suffered from flap loss and one of them was total. No locoregional recurrence or distant metastases were observed. The Goldilocks mastectomy with nipple preservation is an appealing and feasible option for a certain group of patients who have large-sized and/or ptotic breasts. Nevertheless, it is a time-consuming technique with relatively higher rates of flap and NAC complications. Further, studies are required with a larger number of cases and longer follow-up.

Surgical management of nipple areola complex in central breast cancer

Objective: To explore the surgical strategy of nipple areola complex (NAC) management in central breast cancer. Methods: A retrospective analysis was conducted on 164 cases of central breast cancer who underwent surgery treatment from December 2017 to December 2020 in the Breast Center of Beijing Tongren Hospital, Capital Medical University. Prior to the surgery, the tumor-nipple distance (TND) and the maximum diameter of the tumor were measured by magnetic resonance imaging (MRI). The presence of nipple invagination, nipple discharge, and nipple ulceration (including nipple Paget's disease) were recorded accordingly. NAC was preserved in patients with TND≥0.5 cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative intraoperative frozen pathological margin. All patients with signs of NAC involvement, TND<0.5 cm or positive NAC basal resection margin confirmed by intraoperative frozen pathology underwent NAC removal. χ(2) test or Fisher exact test was used to analyze the influencing factors. Results: Of the 164 cases of central breast cancer, 73 cases underwent breast-conserving surgery, 43 cases underwent nipple-areola complex sparing mastectomy (NSM), 34 cases underwent total mastectomy, and the remaining 14 cases underwent skin sparing mastectomy (SSM). Among the 58 cases of NAC resection (including 34 cases of total mastectomy, 14 cases of SSM, and 10 cases of breast-conserving surgery), 25 cases were confirmed tumor involving NAC (total mastectomy in 12 cases, SSM in 9 cases, and breast-conserving surgery in 4 cases). The related factors of NAC involvement included TND (P=0.040) and nipple invagination (P=0.031). There were no correlations between tumor size (P=0.519), lymph node metastasis (P=0.847), bloody nipple discharge (P=0.742) and NAC involvement. During the follow-up period of 12 to 48 months, there was 1 case of local recurrence and 3 cases of distant metastasis. Conclusions: For central breast cancer, data suggest that patients with TND≥0.5cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative NAC margin in intraoperative frozen pathology should be treated with NAC preservation surgery, whereas for those with TND<0.5 cm or accompanied by signs of NAC invasion, NAC should be removed. In addition, nipple reconstruction can be selected to further improve the postoperative appearance of patients with central breast cancer.

Single-Stage Suction-Assisted Lipectomy with Dermal Mastopexy: An Alternative Procedure in Repeated Reduction Mammaplasty with Questionable Nipple-Areola Complex Vascularity.

A majority of malpractice claims in plastic surgery involve complications following breast surgery.1 Nipple-areola complex necrosis is a devastating complication in reduction mammaplasty secondary to compromised vascular supply. The risk of nipple-areola complex necrosis increases in repeated reduction mammaplasty, particularly when the previously used technique is unknown and operative reports are unobtainable. The appropriate technique for repeated reduction mammaplasty remains controversial, as several approaches have been advocated in the literature.2 Many of these techniques involve full-thickness incisions and wide tissue excision for volume reduction, and thus carry the intrinsic risk of nipple-areola complex necrosis due to violation of the underlying vasculature. Suction-assisted lipectomy with dermal mastopexy is a novel technique for repeated reduction mammaplasties to preserve nipple-areola complex vasculature and sensation. An inverted-T de-epithelialization is marked preoperatively (Fig. 1). Each breast is instilled with 1 liter of tumescent solution consisting of 1 liter of Ringer’s lactate with 1:1,000,000 epinephrine and 50 cc of 1% lidocaine. De-epithelialization is undertaken while the breast is tumesced, and the raw surface provides access points for suction-assisted lipectomy. Liposuction is accomplished using a MedGyn Rigid Currette size 7 (MedGyn Products, Addison, Ill.). After suction-assisted lipectomy, dermal mastopexy is completed with interrupted sutures, imbricating the dermal surface.Fig. 1.: Intraoperative views of suction-assisted lipectomy with dermal mastopexy. The midline axis, inframammary fold, nipple-areola complex, distance from sternal notch to nipple, and incision lines were marked along the breast (left). There was much less excess skin in repeated reduction mammaplasties than in primary reductions, and the nipple-areola complex rarely had to be moved more than a couple of centimeters. De-epithelialization of the breast then provides access for suction-assisted lipectomy (right).Eleven suction-assisted lipectomy with dermal mastopexy procedures were performed from 2008 to 2019. The median patient age was 43 years (±9.9 years) and the median time between reductions was 14.5 years (±5.9 years). Average total volume reduction per breast was 800 cc (±200 cc). There were no intraoperative complications in the cohort. Two patients had postoperative complications of wound dehiscence requiring eventual return to the operating room for hypertrophic scar revision. After a follow-up period of 6 months, all patients reported intact nipple-areola complex sensation, and nipple-areola complex vasculature was preserved in all cases. All patients reported decreased symptoms associated with macromastia, such as rashes and back pain. All patients reported satisfaction with their final breast size and symmetry. Aside from aesthetic considerations, any breast reduction must also take oncologic considerations into account. Preoperative imaging was performed in most of our patients to identify malignancies and serve as a comparative baseline for future mammograms. Reduction mammaplasty with liposuction has been shown to trigger deep intraparenchymal calcification development.3 Most of these changes are macrocalcifications, however, and are rarely confused with malignant-appearing microcalcifications when reviewed by experienced radiologists.3 The evidence suggests that liposuction with dermal mastopexy does not interfere with detection of malignancies any more than traditional techniques.4 In this small review, we show that repeated reduction mammaplasty can be as complication-free as the initial reduction with nipple-areola complex preservation. Furthermore, this approach can be critically useful in the setting of unknown prior surgical techniques. Limitations to our study include our small sample size and lack of a standardized comparison group. Furthermore, while suction-assisted lipectomy is a favorable approach for breasts composed largely of fatty tissue, this technique is not appropriate for breasts composed of mostly glandular tissue.5 Therefore, suction-assisted lipectomy with dermal mastopexy may offer a significant advantage for older patients due to the progressive fatty involution of breast tissue with age. DISCLOSURE The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.

Free nipple grafting is a Good technique in enhancing Aesthetics of Breast Cancer Surgery

Background: Mastectomy in breast cancer patients still has significant negative psychological impact. Therefore, restoring body image is fundamental to the quality of these women’s lives and breast reconstruction has become an important tool. The nipple-areola complex (NAC) is the central focus of the breast that enhances its aesthetic appearances. NAC preservation is commonly achieved via lipodermal pedicles (nipple-sparing mastectomy) or dermo-glandular pedicle (breast reduction). However, NAC preservation may not be achievable for a variety of reasons; either oncological or technical.

Prepectoral immediate breast reconstruction with polyurethane foam-coated implants: Feasibility and early results in risk-reducing and therapeutic mastectomies

There is a renewed interest for prepectoral reconstruction. We aimed to describe the feasibility and the early complications associated with immediate one-stage direct-to-implant (DTI) reconstruction using prepectoral anatomical polyurethane (PU) foam-coated implants alone, for women with breast cancer or mutation carriers undergoing risk-reducing surgery. We performed a single-center, retrospective review of 50 patients (mean age of 49 years), who underwent skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and immediate prepectoral PU implant-based reconstruction. All procedures were performed by the same senior operator, from July 2018 to March 2020. A total of 64 mastectomies (25 SSMs and 39 NSMs) with one-stage prepectoral PU foam-coated implant reconstruction were performed. Out of 50 patients, 6 required surgical revision within 30 days, because of hematoma (2), wound dehiscence (2) infection (1), and full thickness nipple-areolar complex (NAC) necrosis (1). Four patients developed a cutaneous rash with spontaneous resolution. Statistical analysis showed a significant influence of hypothyroidism and previous radiotherapy on the risk of complications. The association with prior radiotherapy (pRT) was not significant using binary logistic regression. When excluding oncological reasons and patient's wish for NAC excision, our decision to perform an NSM was influenced by breast cup size, preoperative measurements, and breast weight. Early experience with immediate prepectoral DTI reconstruction with PU-covered implants alone suggests that it is a reliable procedure. Prior breast irradiation does not increase postoperative complication rates in our series. NAC preservation was decided according to preoperative lower breast measurements.

Feasibility of conservative breast surgery in retroareolar breast cancer

Objective: The study aimed to evaluate the feasibility of breast conservative surgery in patients with retro-areolar breast cancer Background: Centrally located tumors have long been thought to vave high incidence of multi-centricity and multi-focality and classically treated with mastectomy Methods: Eighteen female patients with Stage I or IIa retro-areolar breast cancer that were ≥ 1 cm away from nipple-areolar complex, were enrolled for our study at General Surgery Department, Menoufia University, from January 2014 to December 2015. Patients were fully assessed preoperatively. After patients’ counseling and consent, all patients were subjected to lumpectomy with nipple-areola complex preservation. All patients were offered post-operative radiotherapy. Post-operative complications were recorded. Oncological and cosmetic outcome and patient satisfaction were evaluated Results: The resection margins of the excised mass were 1.283±0.583 cm and were found to be clear of malignant cells in all patients. Axillary lymph nodes were positive for malignancy in 6 patients (33.33%) (p 0.157). 13 patients (72.22%) had invasive ductal carcinoma on postoperative histopathology (p 0.002). 6 patients developed postoperative complications (p 0.001). Recurrence occurred only in 2 patients after 12 and 18 months (p 0.001). The cosmetic outcome was excellent in 9 patients, good in 7 patients and fair in 2 patients (p 0.115). 16 patients (89%) were satisfied by the end results (p 0.001). Conclusion: Breast conserving surgery is a feasible procedure for retro-areolar breast cancer.

The utility of intraoperative retroareolar margin frozen section assessment and the management of atypical epithelial proliferative lesions at the retroareolar margin in nipple-sparing mastectomies

ObjectivesNipple-sparing mastectomy (NSM) has become more frequently utilized due to superior psychological and cosmetic outcomes. The aim of this study was to evaluate the accuracy and utility of intraoperative frozen section evaluation of the retroareolar margin (RAM) in NSM. The management of atypical epithelial proliferative lesions at the RAM was also reviewed and discussed. MethodsA single institution, retrospective analysis was performed on all therapeutic NSM patients with intraoperative evaluation of the RAM from 2014 to 2018. Patient demographics, tumor characteristics, pathologic assessment of the RAM, surgical management, and clinical follow-up were reviewed. ResultsSeventy-four nipple-sparing mastectomies with intraoperative evaluation of RAMs were identified. Concordance was 95% between frozen and permanent section diagnoses with 4 cases representing false negatives and no false positives. There were no instances of nipple-areolar complex (NAC) recurrence in all cases with preserved NACs (mean follow up: 750 days). In the 9 cases where NACs were excised based on intraoperative RAM evaluation, the findings in the excised NACs were negative in 6 and ductal carcinoma in situ in 3 cases. Postoperative measurement of the tumor to nipple distance was the only statistically significant variable associated with a positive RAM by multivariable logistic regression (OR 0.475; 95% CI 0.238–0.946). ConclusionsIntraoperative RAM evaluation demonstrated high concordance with permanent histology. Negative RAM, including atypical epithelial proliferative lesions, led to NAC preservation without recurrence. Positive RAM alone did not predict NAC involvement, although pagetoid spread of ductal carcinoma in situ along nipple ducts may predict NAC positivity.

Multi-center investigation of breast reconstruction after mastectomy from Chinese Society of Breast Surgery: A survey based on 31 tertiary hospitals (CSBrS-004).

ObjectiveMulti-center data on the current status and trends of breast reconstruction after mastectomy in China are lacking. Herein, we conducted a cross-sectional survey to investigate the current clinical practice pattern of postmastectomy breast reconstruction among Chinese female patients with breast cancer.MethodsA standardized questionnaire used to collect information on breast reconstruction among females diagnosed with breast cancer was distributed by 31 members of the Chinese Society of Breast Surgery between January 1, 2018 and December 31, 2018. Information was collected on tumor characteristics, treatment, mesh application, nipple-areola complex (NAC) preservation, postoperative complications, bilateral reconstruction, patient satisfaction and local recurrence. The overall rate of breast reconstruction was assessed, and the characteristics were compared across patient groups with different reconstruction approaches.ResultsA total of 1,554 patients underwent breast reconstruction after total mastectomy, with a reconstruction rate of 9.6%. Among them, 1,190 were implant-based, and 262 underwent autologous reconstructions, while 102 cases underwent a combination of both. Patients who underwent implant-based reconstruction were younger than those who received autologous reconstruction (40.1±4.6 vs. 45.0±5.9, P=0.004). Compared to patients with autologous reconstruction, mesh application (25.5% vs. 6.5%), NAC preservation (51.8% vs. 40.5%) and reconstruction failure (1.8% vs. 0) were more frequently reported among those with implant-based reconstruction. There was no significant difference in general satisfaction across three reconstruction approaches, though patients with autologous reconstruction reported the highest aesthetic satisfaction among the three groups (P=0.044). ConclusionsImplant-based breast reconstruction remains the dominant choice among patients, while autologous reconstruction was associated with higher aesthetic satisfaction. Our multi-center investigation based on the findings of the tertiary hospitals of Chinese Society of Breast Surgery may guide a future series of clinical studies on breast reconstruction in China.

Retrospective analysis between complication and nipple areola complex preservation in direct-to-implant breast reconstruction.

Since the introduction of skin-sparing mastectomy (SSM), more breast surgeons have been preserving the areola and often nipple areolar complex (NAC) entirely. For better outcomes, more studies are necessary to analyze whether preserving the areola or NAC is unfavorable in breast reconstruction. The aim of this study was to assess the potential risk of areola or NAC preservation in direct-to-implant (DTI) breast reconstruction after SSM. We retrospectively reviewed the medical records of patients who underwent immediate breast reconstruction from May 2011 to July 2017. Immediate breast reconstruction was performed with DTI procedure in all cases. In total, 213 breasts met the inclusion criteria and were divided into 3 groups: nipple-sparing mastectomy (NSM), aerola-sparing mastectomy (ASM) which only nipple is excised, and skin-sparing mastectomy (SSM) which whole NAC was excised. Complications including infection, capsular contracture, skin necrosis and explantation were measured. The mean patient age was 45.3 years, with a range of 27-62 years; the mean follow-up was 3.08 years. NSM, ASM and SSM groups consisted of 121, 30 and 62 breasts, respectively. The Infection rates were statistically lower in SSM group (4.8%) compared with NSM group (15.7%) (P=0.033) but not statistically different from ASM group (13.3%) (P=0.210). SSM group showed significantly lower rate of overall complication compared with both NSM and ASM groups (P=0.005, 0.025 respectively). Our research suggests that preservation of the NAC increases the rate of infection and skin necrosis in DTI breast reconstruction.

A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery

IntroductionAccurately predicting nipple-areola complex (NAC) involvement in breast cancer is necessary for identifying patients who may be candidates for a nipple-sparing mastectomy. Although multiple risk factors are indicated in the guidelines, it is difficult to predict NAC involvement (NAC-i) preoperatively even if these factors are evaluated individually. This study aimed to develop a more accurate and practical preoperative NAC-i prediction model using magnetic resonance imaging (MRI). Materials and methodsAll tumors in 252 patients were evaluated using postcontrast T1-weighted subtraction on MRI. ResultsThe receiver operating characteristic curves identified cut-off values for tumor size and tumor-to-nipple distance (TND) as 4 cm and 1.2 cm, respectively. Multivariate analysis demonstrated that TND (p < 0.001), ductal enhancement extending to the nipple (DEEN) (p < 0.001), and nipple enhancement (NE) (p = 0.005) were independent clinical risk factors for pathological NAC-i. A formula was constructed using odds ratios for these three independent preoperative risk factors in multivariate analysis: the MRI-based NAC-i predictive index (mNACPI) = TND × 4 + DEEN × 3 + NE × 1. A total score of ≤4 points was defined as low risk and ≥5 points as high risk. NAC-i rates were 2.4% in the low-risk group and 89.4% in the high-risk group; a significant correlation was observed between the risk group and permanent pathological NAC-i (p < 0.001). Assuming that the NAC was preserved in low-risk patients and resected in high-risk patients, NAC-i was verified using the mNACPI. ConclusionmNACPI may contribute greatly to the improvement of selecting suitable patients for NAC preservation in breast reconstructive surgery while maintaining oncological safety.

Risk-reducing mastectomy: a case series of 124 procedures in Brazilian patients.

Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy, however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncological safety of nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates, and unfavorable events of 62 Brazilian patients that underwent risk-reducing NSM from 2004 to 2018. Patient data were reviewed retrospectively and descriptive statistics were utilized to summarize the findings. The mean patients age was 43.8years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications had occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM. Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncological outcomes and low complication rates in a case series of Brazilian patients.

Risk-reducing adenomastectomy: series of 124 procedures carried out in brazilian patients

Objective: Women with mutations in breast cancer predisposition genes have a significantly higher lifetime risk of developing breast cancer and can opt for risk-reducing mastectomy. Women with positive family history of cancer can also opt for prophylactic surgery as a preventive method in selected cases. Current studies showed reduced risk of developing breast cancer after prophylactic nipple-sparing mastectomy; however, despite the good clinical outcomes, one of the main concerns regarding nipple-sparing mastectomy (NSM) is the oncologic safety and nipple-areola complex preservation. In this study, we aimed to evaluate the indications, complication rates and unfavorable events of 62 Brazilian patients who underwent 124 risk-reducing NSM from 2004 to 2018. Methods: Patient data was reviewed retrospectively and descriptive statistics were utilized to summarize the findings. Results: The mean patients’ age was 43.8 years. The main indication for risk-reducing NSM was the presence of pathogenic mutation (53.3%), followed by atypia or lobular carcinoma in situ (25.8), and family history of breast cancer and/or ovarian cancer (20.9%). There were four (3.2%) incidental diagnosis of ductal carcinoma in situ and one invasive ductal carcinoma (0.8%). From the 124 prophylactic NSM performed, two (1.6%) complications occurred: one (0.8%) infection and one (0.8%) partial nipple necrosis. In a mean follow-up of 50 months, there was one (1.6%) newly diagnosed breast cancer in the 62 patients undergoing prophylactic NSM. Conclusions Our findings demonstrated efficacy and safety to perform NSM as prophylactic surgery with good oncologic outcomes and low complication rates in a case series of Brazilian patients.

2020 special issue: Twenty years of breast reconstruction: Past, present, and future

Breast reconstruction has evolved in the last 25years to provide women with better autologous and implant-based options. The general trends of breast reconstruction have shifted to skin and nipple-areolar complex preservation, resulting in improved aesthetics and patient satisfaction. Autologous reconstruction has made a dramatic movement toward microsurgical reconstruction by free tissue transfer and has addressed lymphedema and breast sensation. Using the patient's own tissues, several aesthetic refinements have led to optimizing the cosmetic appearance of the reconstructed breast. Implant-based reconstruction has improved with the invention of form-stable silicone implants, acellular dermal matrix, and fat grafting. These positive trends will continue into the future. We hope that all women with a diagnosis of breast cancer will have the option of a consultation with a reconstructive plastic surgeon, ideally prior to undergoing resective surgery, to ensure they are aware of all reconstructive options to maximize their reconstructive result.

A novel nipple-areola complex involvement predictive index for indicating nipple-sparing mastectomy in breast cancer patients.

Nipple-sparing mastectomy (NSM) is increasingly used in breast cancer patients, as it offers better cosmetic outcomes and improves quality of life. Nipple-areola complex (NAC) involvement must be accurately determined to identify which patients may be candidates for NSM. We aimed to identify the predictors of NAC involvement and develop a clinical predictive model to determine the patients for whom NAC preservation may be considered. Patients (n = 168) with primary operable breast cancer who underwent subcutaneous mastectomy for breast reconstruction at Saitama Medical Center from July 2013 to December 2017 were selected from the hospital's surgical database. The clinicopathological factors of tumor size ≧ 4cm (p < 0.001), nipple-to-tumor distance (NTD) < 1cm by mammography (p = 0.002), NTD < 1cm by magnetic-resonance imaging (MRI) (p < 0.001), nipple contrast findings by MRI (p < 0.001), tumor in central portion (p < 0.001), multicentric/focal lesion (p < 0.001), and clinical node involvement (p = 0.014) were significantly associated with the presence of NAC involvement. Each predictor was scored 0 or 1. A score of 0-3 points was defined as low risk, 4 points as intermediate risk, and 5-7 points as high risk. Using these classification criteria, NAC involvement rate was determined to be 3.5% in low-risk, 68.7% in intermediate-risk, and 90.0% in high-risk specimens. A significant correlation was observed between the risk group and NAC involvement (p < 0.001). This nipple-areola complex involvement predictive index can be used to determine the appropriate indication for NSM in breast cancer patients who request NAC preservation with more oncological safety.

Immediate breast reconstruction with a wise pattern mastectomy and NAC-sparing McKissock vertical bipedicle dermal flap

Preservation of the nipple-areola complex (NAC) in immediate reconstruction of ptotic and large breasts is surgically challenging. This article presents a modification of the inferior dermal flap ("dermal sling") to a vertical bipedicle flap with NAC preservation. This flap is well described in breast reductions but has never been described in a mastectomy setting. The study reviews data for a case series of 17 breasts in 11 women who underwent breast reconstruction with the new technique. The complication rate was 12%, thus indicating that the vertical bipedicle NAC-sparing flap should be considered a feasible option for breast reconstruction in women with ptotic and/or large breasts.

Preoperative breast MRI: reproducibility and significance of findings relevant to nipple-areolar complex involvement.

Eligibility of nipple-sparing mastectomy has been expanded. The purpose of this study was to evaluate interobserver agreement regarding magnetic resonance imaging (MRI) descriptors important in determining eligibility for mastectomy, and to investigate the significance of enhancement extending to the areola concerning nipple-areolar complex (NAC) involvement. Fifty-one cases with histologically confirmed NAC involvement and 54 cases with negative NAC were enrolled. Two radiologists assessed the following factors: lesion morphology (mass or non-mass enhancement); intra-nipple bright signal; enhancement extending to the areola; abnormal nipple enhancement; and tumor-nipple distance. Factors that showed a significant association with outcome in the univariate analysis were assessed by means of multivariate analysis using a logistic regression model. Interobserver agreement between observers was assessed by calculating κ values (dichotomous variables), or intraclass correlation coefficients (ICCs; continuous variables). In multivariate analysis of the results from the two observers, tumor-nipple distance (observer 1: odds ratio [OR] 0.93; 95% confidence interval [CI] 0.88-0.99; observer 2: OR 0.89; 95% CI 0.83-0.95) and enhancement extending to the areola (observer 1: OR 17.9; 95% CI 1.97-162.2; observer 2: OR 24.0; 95% CI 2.62-219.7) were found to be significant predictors of NAC involvement. A substantial agreement (κ=0.64-0.71) for every dichotomous variable and an almost perfect agreement (ICC=0.86) for continuous variable were observed. Findings of breast MRI for NAC preservation had good interobserver agreement. Enhancement extending to the areola, together with tumor-nipple distance, was significant factors for NAC involvement.

Nipple Areola Complex Involvement in Invasive Carcinoma Breast.

A variety of factors including tumor biology and distance of the tumor from the nipple have been associated with nipple areola complex involvement in patients with breast cancer. Preoperative understanding regarding these factors can help in modifying the surgical options including preservation of nipple areola complex (NAC) and breast conservation. Nipple sparing surgery (breast conservation surgery/skin sparing mastectomy with immediate reconstruction) for breast cancer has gained widespread interest with the aim of achieving oncologically safe and cosmetically acceptable outcome. To study the proportion of cases with nipple areola complex involvement in invasive carcinoma breast and to describe the variables predictive of nipple areola complex involvement in patients undergoing excision of tumor along with NAC for invasive carcinoma breast. A cross-sectional study was conducted among 136 patients who underwent mastectomy in Regional Cancer Center, Thiruvananthapuram. Tumor nipple distance was assessed preoperatively using mammogram and postoperatively by histopathological examination. Nipple involvement was seen only among 4.4%. Preoperative assessment of tumor to nipple distance, tumor size, location, and stage of the disease agrees with the histopathological examination. Only a small proportion of breast cancer has NAC involvement and preoperative assessment could help the surgeon in deciding on the feasibility of NAC preservation.

Oncological safety of nipple-sparing mastectomy in young patients with breast cancer compared with conventional mastectomy.

Although nipple-sparing mastectomy (NSM) is being used more frequently, the oncological safety of NSM remains unclear, particularly in young patients (<35 years). The aim of the present study was to compare the rates of local recurrence (LR), disease-free survival (DFS) and overall survival (OS) in young patients with breast cancer who had undergone NSM or conventional mastectomy (CM). The clinicopathological data of young patients with stage 0–IIB breast cancer who had undergone NSM (163 cases) or CM (194 cases) between 2007 and 2016 were retrospectively analyzed. The log-rank test was used to analyze the differences in the LR, DFS and OS rates between the two groups and multivariate analysis was used to analyze the patient prognostic factors for DFS. The median follow-up time was 49 months. Patients who had undergone CM were more likely to exhibit stage II disease (68.4 vs. 58.3%; P=0.015) and positive lymph nodes (45.9 vs. 33.1%; P=0.014). In the NSM group, LR occurred in 7 (4.3%) cases, systemic recurrence in 15 (9.2%) cases and mortality in 9 (5.5%) cases. In the CM group, LR occurred in 6 (3.1%) cases, systemic recurrence in 27 (13.9%) cases and mortality in 15 (7.7%) cases. There were no statistical differences in the LR, DFS and OS rates between the two groups (P>0.05). Following adjustment for clinical stage, the LR and DFS rates between the two groups exhibited no significant differences. Analysis of the prognostic factors demonstrated that clinical stage, lymph node status, estrogen and progesterone receptor status and human epidermal growth factor receptor 2 status were associated with DFS (P<0.05). NSM is safe for young patients with early-stage breast cancer and provides patients with an improved cosmetic outcome. Furthermore, nipple-areola complex preservation does not increase the risk of recurrence.

Early complications in cases series in implant-based immediate breast reconstruction with a biological acellular matrix during the learning curve of this technique and using 3 different matrices: a case series of 84 breasts

Introduction: We present our experience in implant-based immediate breast reconstruction (IBIBR) with biological acellular matrix during our learning curve and compare the complications with the use of three different matrices. Materials and methods: We did a retrospective study on patients who underwent an IBIBR with acellular matrix after skin sparing mastectomy with or without nipple-areolar complex preservation at the Breast Pathology Unit at University Hospital Vall d’Hebron, Barcelona (Spain) between July 2011 and December 2014. Results: A total of 84 breasts were reconstructed in 71 women. A therapeutic mastectomy was performed in 55 of them (65.5%) and a prophylactic mastectomy in 29 (34.5%). The total rate of complications was 41.67% (35 patients): we found 11 cases of erythema (13.1%), 19 cases of seroma (22.62%), 9 cases of hematoma (10.71%), 17 cases of wound dehiscence (20.24%), 11 cases of skin flap necrosis (13.1%), and 10 cases of reconstruction failure (11.9%). The probability of reconstruction failure was higher in smokers and former smokers (P=0.0011%). There were more complications with the Protexa matrix than with the other 2, Strattice and Tutomesh (P&lt;0.001) and a higher risk of reconstruction failure as well (P=0.03). Conclusions: In our experience the use of acellular matrix in IBIBR can have a high rate of complications, especially during the learning curve. Therefore, the selection of suitable patients and the better matrix is an issue of great importance to achieve favorable results.