Nipple Sparing Research Articles

Our experience with the love handle and its surroundings as a donor area of autologous fat grafting at the radiothreapy demaged breast

Objective Patients who had prior breast reconstruction using implants, subsequently underwent radiotherapy resulting in breast damage, and had received at least one session of fat injection were included in the study. This aim of this study was to determine the rationale behind selecting the “love handle” and its adjacent regions as the primary donor site for fat grafting in this patient group. Materials and Methods This retrospective study included 86 patients who had undergone either nipple sparing or skin-sparing mastectomy between January 2019 - December 2023. The fat from each side was removed equally. The depressed areas within the fat removal site and patient satisfaction were assessed. The evaluation was performed at least 6 months after the last session. Results The mean body mass index was 28.9 kg/m2. Of these patients, 26 (30%) underwent a single session, while 60 patients (70 %) received two or more sessions of fat injection. An average of 120 cc of pure fat graft was extracted from the “love handle” and its adjacent areas during the initial session. Except for one patient, all other patients reported that they were satisfied with the procedure. Conclusion The ‘love handle’ and its surroundings is ideal for these patients due to its proximity to the breast, distance from vital vessels and nerves, ability to yield a sufficient amount of fat in the initial session, the ability for successive sessions as BMI increases, and low complication.

Abstract P3-05-52: Sarcopenia and Post-Mastectomy Breast Reconstruction Outcomes after Radiation Therapy

Abstract Background: Sarcopenia, characterized by the loss of muscle mass, has emerged as a negative prognostic factor in cancer patients. It has been associated with poorer outcomes and increased treatment-related morbidity. Post-mastectomy breast radiation therapy (RT) increases the likelihood of reconstructive complication, with up to 20% of reconstructed women requiring implant removal. The factors that lead to these complications are poorly understood and likely multifaceted. We investigated the relationship between pre-radiation therapy sarcopenia and post-mastectomy reconstruction outcomes. Methods: Chart review was performed to determine demographic, medical, and treatment variables, including reconstruction complication events and failures in breasts treated with mastectomy, immediate reconstruction, and RT. Reconstruction failure was defined as tissue expander or implant removal, resulting in no final reconstruction or autologous reconstruction only. Reconstruction complications included surgical site infection, late infection (1 year post-RT), seroma development, flap necrosis, nipple necrosis, wound dehiscence, capsular contracture, hematoma, extrusion, leak, venous congestion, and unplanned reoperation. An axial slice at the L2 or L3 vertebral body from the radiation therapy planning CT scan was analyzed for skeletal muscle area using a previously validated algorithm, with manual review and adjustment as indicated. Sarcopenia was defined by skeletal muscle index (SMI, skeletal muscle area in cm2 divided by patient’s height squared) below 34.4 cm2/m2. Chi-square, Kaplan Meier, and univariate Cox regression tests were used for analysis. Results: Ninety-nine women with breast cancer who underwent mastectomy, reconstruction, and RT were included in this study. All women had immediate reconstruction: 93 women had tissue expander placement while six women had permanent implant placement. Mean age was 47.5 years (SD 10.6) at diagnosis and median BMI was 24.8. Seventy-six percent were non-smokers, 24% were former smokers, and only 16 (16.2%) and 3 (3.0%) had hypertension or diabetes, respectively. Median follow-up was 2.7 years. Median SMI was 38 cm2/m2 and 18 (18%) met criteria for sarcopenia (SMI < 34.4 cm2/m2). Mastectomy was bilateral in 79 women, skin-sparing in 61, and nipple sparing in 31. Bilateral mastectomy was less frequent amongst women with sarcopenia (61%) compared to 84% of those without sarcopenia (p=0.03). After RT, twenty-three women required unplanned reoperation. Within these 23 women, there were 45 total complications. Complications included surgical site infection (n=18), capsular contracture (n=12), seroma (n=4), wound dehiscence (n=3), and others (n=8). However, only 8 women had reconstructive failure and none were sarcopenic at the time of the RT planning scan. Any complication or failure after RT occurred in similar proportions of patients with and without sarcopenia: 38% and 30%, respectively. Kaplan-Meier curves and univariate Cox regression models showed no significant difference in time to failure (p = 0.380) or time to any event (complication or failure) (p=0.53), between sarcopenic and non-sarcopenic patients. Conclusion: Sarcopenia, using SMI < 34.4 cm2/m2 on pre-radiotherapy planning scans, was not associated with an increased risk of post-radiotherapy reconstructive complication or failure in this selected cohort of non-smokers. Few women had sarcopenia at the time of operation, and results should be validated in a larger series. Citation Format: Yasamin Sharifzadeh, Robert Gao, William S. Harmsen, Jason Klug, Panagiotis Korfiatis, Kimberly Gergelis, Dean A. Shumway, Robert Mutter, Kimberly Corbin. Sarcopenia and Post-Mastectomy Breast Reconstruction Outcomes after Radiation Therapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-05-52.

Mastectomy options for the treatment of ipsilateral breast cancer recurrence after lumpectomy

BackgroundMastectomy is the recommended treatment for ipsilateral breast tumor recurrence (IBTR) in patients who initially received breast conservation surgery (BCS) and radiation. We evaluated the 3 types of mastectomies performed for the surgical treatment of IBTR (nipple sparing (NSM), skin sparing (SSM) and total mastectomy (TM)) to assess surgical complications and local control outcomes among groups. MethodsPatients who developed IBTR after BCS and received mastectomy from 2011 to 2019 were reviewed. Patient characteristics and treatment were analyzed. The incidence of postoperative complications and second breast cancer recurrence were compared. ResultsMastectomy was performed in 113 patients presenting with isolated IBTR (17 NSM, 48 SSM and 48 TM). There was no difference in post-operative complications between groups. At 3-year follow-up, 5 (4%) patients had a second recurrence. Tumor size at IBTR was the only predictor for second recurrence and not mastectomy type or receipt of reconstruction. ConclusionIn patients initially treated with BCS who experienced an IBTR, NSM or SSM mastectomy with immediate reconstruction had low complication rates and no increase in local recurrence compared to the TM group

EP.TH.177Safety profile of SurgiMend Acellular Dermal Matrix and Mentor implant assisted immediate breast reconstruction – Our experience at the Princess Royal University Hospital

Abstract Background ADM (Acellular Dermal Matrix) assisted implant-based immediate breast reconstruction (IBR) is a common technique worldwide. Various ADMs are available manufactured from different sources. The Surgimend ADM (fetal bovine dermis) is fenestrated and rich in type I/III collagen; it is claimed to reduce fluid accumulation and promote healing. Methods Retrospective observational analysis exploring safety profile using combination of SurgiMend MacroPorous (MP)/SurgiMend PRS and Mentor CPG/Mentor Siltex implants between January 2018 to December 2019. Patients with unilateral/bilateral IBR following Nipple sparing (NSM) or Skin sparing mastectomy (SSM) were included. The primary outcome was minor complications (seroma (>100ml on USS), hematoma, wound infection and infected seromas). Secondary outcome was major complications (flap necrosis, capsular contracture, implant explantation and Red Breast Syndrome). Results Six (16.2%) bilateral and 31 (83.8%) unilateral IBR were performed in 37 patients. Mean age was 53.78 years. No major complications were recorded. Conclusions The Surgimend ADM and Mentor implant combination demonstrate a good safety profile. Higher rates of seroma in this study could be explained by overdiagnosis and treatment at our unit, which in turn might imply as a result that no major complications were detected and no implant loss.

Minimally Invasive Mastectomy Could Achieve Non-inferior Oncological Outcome in Appropriately Selected Patients: Propensity Matched Analysis of the National Cancer Database.

Minimally invasive mastectomy (MIM) was emerged as an approach to decrease morbidity and increase patient satisfaction through improved cosmetic results; however, there is a paucity of data regarding the long-term oncologic outcomes of these minimally invasive approaches. Patients who underwent mastectomy procedures were identified in the National Cancer Database (2010-2016). Patients were categorized as MIM or open mastectomy. A 1:1 propensity match was performed to balance the bias on reconstruction, nipple sparing, lymph node procedures, and other confounding factors between the cohorts. Short- and long-term outcomes were compared. A total of 328811 patients met the criteria: 327643 (99.6%) received open mastectomy and 1168 (.4%) received MIM. Propensity match identified 384 "pairs" of MIM and open mastectomy patients. Among them, MIM was associated with shorter length of stay (LOS) (mean 1.3 vs. 1.06 days, P = .003). No differences were observed in the rates of positive margins, unplanned readmissions, or 90-day mortality between the 2 operative approaches. Overall survival (OS) was equivalent between MIM and open mastectomy patients. Cox proportional hazard regression showed no effect of the procedure performed on OS. MIM is associated with shorter LOS, and it is non-inferior to open mastectomy in terms of other short-term outcomes and long-term oncologic survival outcomes. These data suggest that MIM may be considered in appropriately selected breast cancer patients as an additional approach to the community.

Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.

Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions. Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions. Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034). Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.

Our first experience of prepectoral reconstruction of the mammary gland using a mesh polypropylene implant

Purpose of the study. To study the results of prepectoral reconstruction of the mammary gland after subcutaneous mastectomy for cancer with additional covering of the implant with a polypropylene mesh implant. (IPPBR) Materials and methods. Case-series of 6 patients with luminal breast cancer T1–2N0M0 aged from 34 to 47 years. IPPBR was performed after subcutaneous mastectomy (nipple sparing in 2 cases). The anterior surface of implants (Polytech, Germany) was covered with Ethicon/Johnson& Johnson (USA) simple polypropylene mesh. The mesh was fixed with interrupted absorbable sutures to the big pectoral muscle. Results. There was one successfully treated minor complication: limited skin incision necrosis. No other complications or tumor recurrences were registrated during observation period. The aesthetic results (mainly shape and volume breasts symmetry, nipples symmetry after nipple- sparing operation) were estimated as good both by surgeon and all patients. Periprosthetic connective tissue growth was minimal (grade I due to Baker’s scale) in all cases. Conclusion. The first results of the use of a simple mesh polypropylene implant in cases of breast cancer after subcutaneous mastectomy for cancer for the prevention of implant migration are encouraging. The degree of development of periprosthetic scar contracture is minimal.

Nipple sparing: standard of care?

Nipple sparing: standard of care?

Abstract P4-13-08: Robotical-assisted laparoscopy for latissimus dorsi flap harvesting in breast reconstruction : A 23 consecutive cases report

Abstract Background : Latissimus dorsi (LD) flap is a classic and usual procedure for immediate or secondary breast reconstruction with good results and poor complication rate. The principal issue is the long and often painful dorsal scar. The feasibility of laparoscopic LD flap harvesting and more recently robotically-assisted laparoscopy were described in short series. We report in this article the largest series of robotically-assisted laparoscopic LD flap harvesting. We describe its feasibility and the immediate and early post operative outcomes. Material et methods : Between January 27th and December 21th of 2016, we performed 23 robotically-assisted laparoscopic LD flap harvestings in immediate and secondary breast reconstruction. Every patient was systematically sent for an evaluation of aesthetic result, pain and satisfaction on the second, the sixth and the twelth month. Results : 78,3% of surgeries were realized for infiltrative breast cancer.17 (73,9%) LD flaps were harvested in immediate reconstruction after nipple or skin sparing mastectomies (NSM -34,8%-or SSM -43,5%). The global mean operative time was 360,1 minutes, including bilateral and robotically-assisted mastectomies. The mean hospital stay duration was 5 days (2-8 days). We described one failure for secondary LD flap reconstruction (infection). The other cases resulted in successful reconstructions without heavy complications. Discussion :Our series is the largest reported. It confirms the feasibility of a robotically-assisted procedure in breast reconstruction with LD flaps. Our study describes a reliable option for LD flap breast reconstruction without any additional scar. Some procedures were combined in selected patients with a robotic NSM with a single axillar incision. Citation Format: Houvenaeghel G, Rua S, Franké O, Cohen M, Lambaudie E. Robotical-assisted laparoscopy for latissimus dorsi flap harvesting in breast reconstruction : A 23 consecutive cases report [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-08.

Prophylactic Bilateral Nipple-sparing Mastectomy and a Staged Breast Reconstruction Technique: Preliminary Results.

More high-risk women with breast cancer are identified using genetic testing at a younger age. These young women often opt for prophylactic surgery. Most patients are reluctant for extra donor-site scars besides infections and necrosis. In order to reduce these risks, a two-stage breast reconstruction technique is used for high-risk women with large or ptotic breasts. We presume that this procedure will reduce the risk of skin envelope and nipple–areola complex (NAC) necrosis to less than 1%. In the first stage, an inferior pedicle reduction is performed to obtain large volume reduction with maximal safety for the NAC. The ptosis, skin excess, and malpositioning of the NAC are corrected safely at this stage. In the second stage, the skin-sparing mastectomy is performed with or without nipple sparing. During this procedure, the areola is never removed. A bilateral breast reconstruction is then performed with an immediate subpectoral prothesis or delayed with the use of a subpectoral tissue expander. In this way, we aim to meet the patient’s wish to undergo bilateral risk reducing mastectomy in breasts that need ptosis correction without donor-site scarring. This article describes the procedure and reports the preliminary data.

The micropolyurethane foam-coated Diagon/Gel(®)4Two implant in aesthetic and reconstructive breast surgery - 3-year results of an ongoing study.

Background: Breast implants are worldwide in use since 1962. Initially there were some problems with capsular contracture and the palpability of the rim of the implant. In 1968 this led to the introduction of the micropolyurethane foam-coating and then in 1970 to the first micropolyurethane foam-coated implant by F.A. Ashley. As a result of additional technical refinements in manufacturing this new implant design significantly reduced complications i.e. capsular contracture and implant rotation. Methods: This study reports a single surgeon’s experience with aesthetic and reconstructive breast surgery, in primary and secondary cases with the sole use of micropolyurethane foam-coated Diagon/gel®4Two implants, partly in combination with the additional use of synthetic meshes, acellular dermal matrices and lipofilling. The trial is a prospective, single center cohort study designed to demonstrate the safety and effectiveness of the new implant design in primary and secondary aesthetic and reconstructive breast surgery. The reported data provide an interim report of the implantations performed from November 2010 to December 2013.Results: 90 patients were admitted to the study with 152 implants. The majority of the implants (n=95, 62.5%) were used in reoperative cases for either oncological (n=52, 34.2%) or aesthetic reasons (n=43, 28.3%). The median age of the study cohort was 45 years; the median body mass index was 21; the median observation time is 41 months. There was a very low complication rate, both short term within 6 weeks after the implantation of the silicone gel implant and in the follow up in November 2015. There were no serious complications needing explantation, no capsular fibrosis or implant rotation or rupture so far. There were only 4 minor complications (1.97%). There was 1 local recurrence 4 years after skin and nipple sparing mastectomy.Conclusion: The micropolyurethane foam-coated Diagon/gel®4Two implant is a very reliable silicone gel implant filled with two high cross-linked, cohesive and form stable gels. The study demonstrated a very high safety profile of the 4Two implant and its effectiveness in both primary and secondary reoperative aesthetic, oncological and reconstructive breast surgery. The study is ongoing, a longer follow-up will be needed to consolidate the data.

A Comparison of Clinical and Pathologic Assessments for the Prediction of Occult Nipple Involvement in Nipple-Sparing Mastectomies

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy. The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted. Using clinical criteria alone, the false negative rate was 53.8% and a false positive rate of 44.4%. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7% but the false positive rate remained at 44.4%. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8%. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive. This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.

Prophylactic contralateral surgery: current recommendations and techniques

The use of contralateral prophylactic mastectomy (CPM) from both invasive cancer and ductal carcinoma in situ is increasing in the United States [1], in spite of the fact that only 3% of breast cancer patients in the Surveillance, Epidemiology, and End Results database developed a contralateral cancer at 5 years [2]. Endocrine therapy and trastuzumab, both widely used as adjuvant therapy, reduce the incidence of contralateral cancer by about 50%, suggesting that the risk of contralateral cancer in women treated today is quite low. Most guidelines for prophylactic mastectomy address women at high risk, not women with unilateral cancer. Known or suspected BRCA mutation carriers who develop unilateral cancer have a 40 to 60% risk of developing a contralateral cancer, and CPM is accepted as appropriate therapy in this circumstance. To address the issue of what kind of women undergo CPM, we identified 477 patients who had the procedure at Memorial Sloan-Kettering Cancer Center within 1 year of a unilateral cancer diagnosis and compared them with 2,500 women undergoing unilateral mastectomy in the same period (1997 to 2005). CPM patients were younger (median 46 vs 53 years; P < 0.0001), had smaller tumors (1.2 vs 1.8 cm; P < 0.0001), and were less likely to have positive nodes (47 vs 57%; P < 0.0001). Hormone receptor and HER2 status did not differ between cases and controls. Although 68% of CPM patients reported a family history of breast cancer, only 2% underwent genetic testing. Of these, 34 (7%) were found to have a mutation. The pathology specimens of 6% of patients undergoing CPM were found to contain malignancy (eight invasive, 20 ductal carcinoma in situ). When CPM is performed, it should be done to the same anatomic limit as a therapeutic mastectomy. Skin sparing to facilitate reconstruction is appropriate, but flaps should be the same thickness as is used in a therapeutic mastectomy. The use of nipple sparing is controversial [3]. In order to maintain a blood supply to the nipple areolar complex, some breast tissue must be left behind. Most studies of local recurrence after nipple preservation have been limited to patients with breast cancer, and little is known about its use in the prophylactic setting, particularly regarding risks in BRCA carriers. However, local recurrence is uncommon after nipple sparing for cancer treatment, and improved body image and psychological adjustment after nipple sparing has been reported [3], making this option worthy of consideration in patients undergoing CPM.

350 POSTER Necrotic complications after nipple and areola sparing mastectomy

350 POSTER Necrotic complications after nipple and areola sparing mastectomy

Envelope mastectomy with immediate reconstruction (EMIR)

Aims: To develop an oncologically safe and aesthetically acceptable technique for mastectomy, using a muscle flap and tissue expander through one incision. Methods Twelve consecutive patients (mean age 40) underwent an envelope mastectomy (skin and nipple sparing), with immediate reconstruction with a latissimus dorsi muscle flap and tissue expander. Assessment of cosmesis was by review of pre- and post-operative photographs by an independent observer. Results During follow-up there have been no recurrences. Assessment of cosmesis gave a score of 44 out of 48 (92%). One prosthesis was removed due to erosion of the prosthesis through the skin. Conclusions In patients with large lesions, multi-focal lesions (both invasive and in situ) and recurrent phyllodes tumours may undergo an oncologically safe mastectomy with immediate reconstruction through a single incision that is inconspicuous being in the mid-axillary line. Although follow up is only 8.5 months, long-term studies are being undertaken.