Skin-sparing Mastectomy Patients Research Articles

Bilateral Implant-based Breast Reconstruction with Unilateral Radiotherapy: A Matched Cohort Study Comparing Nipple-sparing Mastectomy and Skin-sparing Mastectomy.

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

D134. Comparison of Nipple-sparing Mastectomy versus Skin-sparing Mastectomy in Bilateral Implant-based Breast Reconstruction with Unilateral Radiotherapy: A Matched Cohort Study

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

Double Asymmetric Circular Incision, a New Skin-Sparing Mastectomy Technique: Results and Outcomes of the First 46 Procedures.

Skin-sparing mastectomy (SSM) is a surgical technique that preserves as much of the breast skin as possible. Double asymmetric circular incision (DACI) is a novel immediate breast reconstruction technique for immediate prepectoral implant placement using a titanium-coated polypropylene mesh. The aim of this technique is to optimize the cosmetic benefits of smaller incisions, preserve breast anatomy, avoid breast deformities, and reduce the negative psychological impact on the patient without increasing local recurrence risk. DACI SSM uses a double circular incision: the external drawing contains the nipple-areola complex, while the inner circular skin island is used to provide the skin for the new areola. The authors performed DACI SSM in patients with tumors located within 2 cm of the nipple-areola complex, or in patients with multicentric lesions involving areolar tissue. Forty-six patients underwent DACI SSM at the authors' institutions between February of 2014 and July of 2019. Two patients developed hematoma, and one patient developed seroma. No implant loss was observed. Skin flap necrosis rate was 0%. The BREAST-Q patient-reported outcomes measure was routinely used at the authors' institutions and recorded good aesthetic outcomes and high patient satisfaction. This new technique appears to be safe and easily reproducible in patients with small to medium-sized breasts and with little to moderate ptosis (up to Regnault classification grade II). Therapeutic, IV.

65 (PB-065) Poster - Quality of life and patient satisfaction after nipple sparing mastectomy versus skin sparing mastectomy and immediate one stage versus two stages breast reconstruction

Background: Nipple Sparing Mastectomy (NSM) and Skin Sparing Mastectomy (SSM) are oncologically safe procedures compared to classical modified radical mastectomy. This study evaluates whether NSM patients are more satisfied and have better quality of life than matched SSM patients and assesses patients’ quality of life after immediate one stage breast reconstruction with prepectoral permanent implants (IBR) compared to a matched group undergoing two stages breast reconstruction with expander and later with permanent implant.

Nipple-Sparing Mastectomy and Immediate Reconstruction: A Propensity Score-Matched Analysis of Satisfaction and Quality of Life.

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

Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates

Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns. A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery. Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts. In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.

Skin Reducing Mastectomy and Immediate Tissue Expander Reconstruction: A Critical Analysis.

Complications of implant-based reconstruction have been shown to be related to increasing body mass index (BMI) and breast size. The impact of skin reducing mastectomy (SRM) with a dermal flap is examined. A retrospective review of a single surgeon's experience with immediate submuscular tissue expander (TE) reconstruction from 2011 to 2019 was performed. The outcomes of SRM were compared with those of skin sparing mastectomy (SSM). A total of 162 patients (292 breasts) were identified. Mastectomy types were as follows: SRM, 73 (136 breasts) and SSM, 89 (156 breasts). Acellular dermal matrix (ADM) was used to supplement TE coverage in 65.4% of SRM cases. Mean BMI was 29.2 among SRM patients and 25.9 in SSM patients (P < 0.001). Obesity (BMI ≥ 30) was more prevalent in the SRM group (SRM, 38.4% vs SSM, 22.5%; P = 0.03). Mean mastectomy weight was higher in the SRM group (SRM, 833.6 g vs SSM, 425.6 g; P < 0.001). Mean BMI and mastectomy weight were lower in SRM patients who were reconstructed with ADM (ADM, 28.1 vs no ADM, 30.8; P = 0.01; ADM, 746.1 g vs no ADM, 1006.3 g; P < 0.001). Minor complications were more prevalent in the SRM group (SRM, 22.8% vs SSM, 4.5%; P < 0.001). Mastectomy skin flap necrosis (MSFN) was more common in the SRM group (SRM, 22.8% vs SSM, 7.7%; P < 0.001), but MSFN necessitating operative debridement was similarly low in both groups (SRM: 1.9% vs SSM: 4.5%). Major complication rates (SRM 11.0% vs SSM 10.9%) and reconstructive failure rates (SRM 5.9% vs SSM 5.1%) were similar between groups. Mastectomy weight 800 g or higher and BMI of 30 or higher were found to be risk factors for complications on analysis of the SRM cohort (P < 0.05). Mastectomy weight and BMI were positive predictors of complications after immediate TE reconstruction. Mastectomy skin flap necrosis is more common after SRM than SSM. The use of SRM with a dermal flap has a similar major complication rate as SSM despite its use in obese, large-breasted women. The dermal flap provides soft tissue coverage, which prevents implant exposure and seroma. The use of ADM does not adversely affect the complication rate of SRM.

Nipple-Sparing Mastectomy versus Skin-Sparing Mastectomy: Does Saving the Nipple Impact Short- and Long-Term Patient Satisfaction?

Nipple-sparing mastectomy (NSM) is an oncologically safe alternative to skin-sparing mastectomy (SSM). This study evaluated whether NSM patients were more satisfied than SSM patients in short- and long-term follow-up. Women who underwent NSM or SSM between 2009 and 2019 completed a postoperative BREAST-Q survey at least 1 year after surgery and patient characteristics were compared. Patient satisfaction at 1-5years and 6-10years after NSM and SSM were analyzed. Overall, 431 patients were included; 247 had NSM and 184 had SSM 1-10years prior to BREAST-Q survey completion. SSM patients were older, had higher body mass index (BMI), larger breast weight, and more hypertension than NSM patients, but oncologic treatments were similar between groups. BREAST-Q Psychosocial Well-Being and Sexual Well-Being scores were significantly higher in NSM patients compared with SSM patients in the 1-5years cohort; however, scores attenuated in the 6-10years cohort. Satisfaction with breasts was nearly significantly higher in NSM patients compared with SSM patients in the 1-5years cohort (p=0.056), but no different in the 6-10years cohort. Receipt of adjuvant chemotherapy, receipt of postmastectomy radiation therapy, and BMI ≥30 were independent risk factors for dissatisfaction with breasts. Women who are not candidates for NSM should be reassured that long-term qualify of life is not significantly different between SSM and NSM. Dissatisfaction with reconstructed breasts is linked with other factors (besides the nipple), which patients should be made aware of at the time of surgical decision making.

Abstract PS1-36: Outcomes and management of positive and close anterior margins following skin-sparing mastectomy

Abstract Background: Skin-sparing mastectomy (SSM) has emerged as a safe oncologic technique for extirpation of breast tissue in the context of immediate breast reconstruction (IBR). Documented rates of local recurrence are comparable for SSM and conventional mastectomy and attention to the plane of dissection is essential with removal of skin overlying the tumor when clinically indicated. The incidence of positive or close margins is greatest for peripheral tumors at the breast boundaries and will influence rates of local recurrence. Management of positive or close margins is inconsistent and this audit aimed to determine the incidence of compromised margins and their impact on local recurrence and overall survival in SSM patients. Methods: A retrospective analysis was undertaken of breast patients with invasive or non-invasive breast cancer undergoing SSM and IBR at a single tertiary referral centre between January 2006 and December 2009. A total of 150 patients were included and all underwent resection of breast tissue with a peri-areolar incision. Clinical information was extracted from a prospectively maintained database. Data was collected on patient demographics, tumor characteristics, non-surgical treatment and outcome events (recurrence and death). The definition of a negative margin on histology during the study period was tumor ≥2mm from the edge of the specimen with close margins &amp;lt;2mm but no ink on tumor. Results: The mean age of patients was 51 years (range 24 - 75) and median duration of follow up 140 months (range 10 - 167). Amongst these 150 SSM patients, 25 (17%) had positive or close anterior margins (&amp;lt;2mm) with 125 patients having negative anterior margins (&amp;gt;2mm). None of these patients with close or positive margins underwent re-excision following initial SSM. Twenty-four patients (16%) developed either loco-regional (n=9) or distant recurrence (n=15) with 126 patients (84%) alive at 10 years. Although more patients with positive/close compared with negative margins had recurrence (20% versus 15%), this did not reach statistical significance (p=0.55) Similar proportions of patients in each margin category received post-mastectomy radiotherapy (p=0.66) and adjuvant/neo-adjuvant chemotherapy (p=0.66). There were no statistically significant differences in rates of local recurrence or survival between patients with positive/close and negative margins but the number of events is small and may represent a type II error. Conclusion: Twenty percent of patients (5/25) with positive or close margins after SSM develop local or distant recurrence with reduction of risk by PMRT of &amp;lt;50%. None of the patients with positive/close margins who developed recurrence survived for 10 years. Close/positive margins after SSM may portend a worse outcome from recurrent disease and further research is required to optimize management of this group of patients in an era of skin-preserving mastectomy. Citation Format: Primeera Wignarajah, Dorin Dumitru, John R Benson. Outcomes and management of positive and close anterior margins following skin-sparing mastectomy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-36.

Prepectoral reconstruction with polyurethane-coated implant after skin-sparing mastectomy in patients with breast cancer

Breast cancer is one of the most frequently diagnosed malignancies in the Russian Federation (RF), accounting for 20.9% of the female population in Russia. The surgery remains the primary treatment for breast cancer. Development and improvement of various options for reconstructive plastic surgery provides medical, psychological and social rehabilitation in patients with breast cancer, allows to achieve the best aesthetic and functional results. The possibility of performing such operations contributes to improving the quality of life of patients. According to ASPS (American Society of Plastic Surgeons), 80% of breast cancer reconstructions in the world are performed using silicone implants. Currently, the return of prepectoral space for placement of endoprostheses during breast reconstruction is trending, which is associated not only with the improvement of mastectomy techniques, but also with the coating of implants and the appearance of silicone highly adhesive gel filling of implants. According to the world literature data, the use of polyurethane-coated endoprostheses for prepectoral/subcutaneous reconstruction reduces the risk of capsular contracture, provides a more reliable fixation to the surrounding tissues, and thus allows breast reconstruction without the need for additional cover of the endoprosthesis. The use of the prepectoral space is characterized by a simpler operation technique compared to the retromuscular placement of the implant, the absence of damage to the large pectoral muscle, minimization of pain, reduction of the bed-day in the hospital and a faster rehabilitation period. So, this type of breast reconstruction can be considered as an alternative to submuscular implant placement in primary operable forms of breast cancer with sufficient thickness of the integumentary tissues.

Effect of complete pathological response related factors after neoadjuvant chemotherapy on skin-sparing mastectomy and breast reconstruction

IntroductionImmediate breast reconstruction (IBR) after skin-sparing mastectomy in patients undergoing neoadjuvant chemotherapy (NACT) is still controversial. The objective is to determine related factors to the axillary downstaging and complete pathological response (CPR), and how CPR influences the decision of bilateral mastectomy with immediate reduction (IBRBM). Patients and methodsA retrospective analysis breast cancer patients undergoing NACT and IBRBM between 2000–2018 was performed. We compared two groups;1)CPR and 2) not CPR. Descriptive and comparative statistical analysis. Results and Discussion69 patients; 26 (37.68%) reached CPR and 43 (62.32%) non-CPR. Median follow-up of 45.3 months (RIQ:23,0–94,0). Age less than 35 (p < 0.001), small size tumor at diagnosis (p = 0.006) and subtype HER2 (p < 0.001) were associated with higher rates of CPR in univariate analysis. Axillary negativization rate was 80% in group 1 and 59.3% in group 2 and lymphadenectomy rates were similar (73.1% and 83.72%). ConclusionCPR after NACT not conditioned the decision to perform IBRBM.

Factores relacionados con la obtención de respuesta patológica completa tras quimioterapia neoadyuvante en cáncer de mama y su efecto sobre la reconstrucción tras mastectomía ahorradora de piel

IntroductionImmediate breast reconstruction after skin-sparing mastectomy in patients undergoing neoadjuvant chemotherapy is still controversial. The objective of this study is to determine factors related with axillary downstaging and complete pathological response (CPR), and how CPR influences the decision to perform bilateral mastectomy with immediate reduction. MethodsA retrospective analysis of breast cancer patients who had undergone neoadjuvant chemotherapy and bilateral mastectomy with immediate reduction between 2000-2018 was performed. Two groups were compared:1) CPR and 2) non-CPR. Descriptive and comparative statistical analyses are provided. Results69 patients; 26 (37.68%) reached CPR and 43 (62.32%) non-CPR. Median follow-up of 45.3 months (IQR: 23.0-94.0). Age under 35 (p <.001), small size tumor at diagnosis (p=.006) and subtype HER2 (p <.001) were associated with higher rates of CPR in bivariate analysis. Axillary negativization rate was 80% in group 1 and 59.3% in group 2, and lymphadenectomy rates were similar (73.1% and 83.72%). ConclusionsCPR after neoadjuvant chemotherapy did not influence the decision to perform bilateral mastectomy with immediate reduction.

Passot-Type Immediate Breast Reconstruction Obviates the Use of Aceullular Dermal Matrix in Grades 2 and 3 Ptosis

Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM. All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided. Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case). Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment.

High-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients. Women undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0-4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared. NSM was performed on 8173 patients: 8.7% were node positive, and for stage 1-4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients. Over one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

The role of PET and MRI in evaluating the feasibility of skin-sparing mastectomy following neoadjuvant therapy.

ObjectiveTo investigate the role of positron emission tomography (PET) and magnetic resonance imaging (MRI) in evaluating the feasibility of skin-sparing mastectomy in patients with locally-advanced breast cancer (LABC) who will undergo neoadjuvant chemotherapy (NAC) by evaluating the sensitivity and specificity of PET and MRI compared with skin biopsy results before and after NAC treatment.MethodsPatients with LABC who were treated with NAC between November 2013 and November 2015 were included in this study. Demographic, clinical, radiological and histopathological features of the patients were recorded.ResultsA total of 30 patients were included in the study with a mean age of 52.6 years (range, 35–70 years). Sensitivity and specificity for detecting skin involvement in LABC was 100%/10% (62%/85%) with MRI and 60%/80% (12%/92%) with PET before (after) NAC, respectively. When radiological skin involvement was assessed in relation to the final histopathological results, the preNAC PET results and histopathological skin involvement were not significantly different; and there was no difference between postNAC MRI and histopathological skin involvement.ConclusionsAs preNAC PET and postNAC MRI more accurately determined skin involvement, it might be possible to use these two radiological evaluation methods together to assess patient suitability for skin-sparing mastectomy in selected patients.

A 10-Year Experience with Mastectomy and Tissue Expander Placement to Facilitate Subsequent Radiation and Reconstruction.

An integrated approach to skin sparing mastectomy with tissue expander placement followed by radiotherapy and delayed reconstruction was initiated in our institution in 2002. The purpose of this study was to assess the surgical outcomes of this strategy. Between September 2002 and August 2013, a total of 384 reconstructions had a tissue expander placed at the time of mastectomy and subsequently underwent radiotherapy. Rates and causes of tissue expander explantation before, during, and after radiotherapy, as well as tumor specific outcomes and reconstruction approaches, were collected. Median follow-up after diagnosis was 5.6 (range 1.3-13.4) years. In the study cohort, 364 patients (94.8%) had stage II-III breast cancer, and 7 patients (1.8%) had locally recurrent disease. The 5-year rates of actuarial locoregional control, disease-free survival, and overall survival were 99.2, 86.1, and 92.4%, respectively. The intended delayed-immediate reconstruction was subsequently completed in 325 of 384 mastectomies (84.6% of the study cohort). Of the remaining 59 tissue expanders, 1 was explanted before radiotherapy, 1 during radiotherapy, and 7 patients (1.8%) were lost to follow-up. Fifty patients (13.0%) required tissue expander explantation after radiation and before their planned final reconstruction, primarily due to cellulitis. Nonetheless, the cumulative rate of completed reconstructions was 89.6%. The median time from placement of the tissue expander until reconstruction was 12 (interquartile range 9-15) months. Tissue expander placement at skin-sparing mastectomy in patients who require radiotherapy appears to be a viable strategy for combining reconstruction and radiotherapy.

Acellular Dermal Matrix (Permacol®) for Heterologous Immediate Breast Reconstruction after Skin-Sparing Mastectomy in Patients with Breast Cancer: A Single-Institution Experience and a Review of the Literature.

Skin-sparing mastectomy (SSM) with immediate heterologous reconstruction is a safe oncological option in surgical therapy of early breast cancer. Permacol® is an acellular dermal matrix (ADM) placed between the implant and the skin to improve lower pole projection and implant coverage. The aim of our study was to evaluate the outcome with a focus on patient satisfaction after 6 months and to analyze physical changes of ADM. 10 patients who underwent SSM with Permacol® were analyzed retrospectively. All patients were followed using a satisfaction questionnaire and an ultrasound evaluation of the tissue thickness of the pectoralis muscle and the Permacol®. No intraoperative complications were observed. One patient required removal of the implant for necrosis after 3 months. Half of the patients underwent secondary corrective surgery. A statistically significant thinning of the pectoralis muscle was observed, compared to the thickening of the Permacol®. A majority of the patients were satisfied with the operation, and we found a correlation between lower body mass index and patient satisfaction. In our small case series Permacol®-assisted immediate reconstruction is shown to be an option for selected cases. Physical changes of Permacol® result in a symmetrical coverage of the implant, which may improve cosmetic outcome.

Oncologic Safety of Immediate Breast Reconstruction for Invasive Breast Cancer Patients: A Matched Case Control Study.

PurposeThe purpose of this study was to compare locoregional recurrence-free survival (LRFS) and disease-free survival (DFS) between patients undergoing mastectomy and immediate breast reconstruction (IBR) and those undergoing mastectomy alone.MethodsA retrospective review of patients who underwent mastectomy and immediate breast reconstruction for resectable invasive breast cancer between 2002 and 2010 at a single center was conducted. These cases were matched to patients who underwent mastectomy alone in the same time period, performed by 1:2 matching. Matching control variables included age, tumor size, axillary lymph node metastasis, and estrogen receptor status. Overall, 189 patients were identified in the IBR group, and 362 patients were matched to this group.ResultsIn the IBR group, 75 patients (39.7%) underwent conventional total mastectomy, 78 (41.3%) underwent skin-sparing mastectomy (SSM), and 36 (19.0%) underwent nipple-sparing mastectomy (NSM). The IBR group was significantly younger than the control group (41.9 and 45.1 years, respectively) (p=0.032), in spite of matching between three age groups. The DFS rates were similar between the IBR group and mastectomy alone group, at 92.0% and 89.9%, respectively, at 5-year follow-up (log-rank test, p=0.496). The 5-year LRFS was 96.2% in the IBR group and 96.4% in the mastectomy alone group (log-rank test, p=0.704), similar to data from previous reports. Subgroup analyses for SSM or NSM patients showed no differences in LRFS and DFS between the two groups. Additionally, in stage III patients, IBR did not cause an increase in recurrence.ConclusionIBR after mastectomy, including both SSM and NSM, had no negative impact on recurrence or patient survival, even in patients with advanced disease.

Oncologic safety of conservative mastectomy in the therapeutic setting.

Conservative mastectomy is a form of nipple-sparing mastectomy which is emerging as a surgical option for selected breast cancer patients. This technique differs from subcutaneous mastectomy which is well established as a technique for risk reduction but leaves behind a finite remnant of retro-areolar breast tissue. Clinical trials have confirmed the efficacy and safety of breast conservation therapy for smaller localised breast tumors whereby a variable amount of surrounding normal tissue is excised with administration of breast radiotherapy post-operatively. Conservative mastectomy aims to remove all breast tissue with dissection continued into the core of the nipple. However, the indication for conservative mastectomy remains to be defined but generally includes tumors of modest size located at least 2 cm away from the nipple. Patients undergoing conservative mastectomy do not necessarily receive adjuvant radiotherapy and this may only be intra-operative irradiation of the nipple-areola complex (NAC). Preservation of the NAC as part of a skin-sparing mastectomy in patients who might otherwise require standard mastectomy is of unproven safety from an oncologic perspective but is associated with enhanced cosmetic outcomes and quality-of-life. The advent of conservative mastectomy has coincided with a trend for "maximal surgery" with bilateral extirpation of all breast tissue in conjunction with immediate breast reconstruction. It is essential there is no compromise of local recurrence and survival in terms of ipsilateral breast cancer treatment. Further studies are required to clarify the indications for conservative mastectomy and confirm oncologic equivalence to either wide local excision and breast irradiation or conventional/skin-sparing mastectomy with sacrifice of the nipple areola complex.

195. Skin sparing mastectomy and immediate reconstruction for locally advanced breast cancer after neoadjuvant chemotherapy

Background: Skin-sparing mastectomy (SSM) followed by immediate reconstruction (IBR) is a safe and commonly used treatment for patients with early-stage breast cancer. However, the safety and efficacy of SSM in patients with high-risk disease have not been well studied. The implementation of neoadjuvant chemotherapy for a selected group of patients with locally advanced breast cancer followed by skin sparing mastectomy and immediate reconstruction expands the scope of breast preservation to encompass more patients with large tumors and improves the final aesthetic outcome.