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Breast Reconstruction Outcomes Following Nipple-Sparing Mastectomy
Amy S. Colwell, MD, Oren Tessler, M.D., Alex M. Lin, B.S., Eric Liao, M.D., Jonathan Winograd, M.D., Curtis L. Cetrulo, M.D., Rong Tang, M.D., Barbara L. Smith, M.D., William G. Austen, Jr., M.D..
Massachusetts General Hospital, Boston, MA, USA.
Nipple-sparing mastectomy (NSM) is increasingly used for treatment and prevention of breast cancer. A growing body of oncologic literature supports its safety and efficacy. Little data exists to categorize risk factors for complications in NSM reconstruction and to determine if these factors impact reconstruction type. We review breast reconstruction outcomes over a five-year period.
Single institution retrospective review was performed between 1/07-4/12 for NSM procedures and immediate or delayed reconstruction.
Two hundred eighty-five patients, median age 46 years (range 25-78), underwent 500 nipple-sparing mastectomy procedures for breast cancer treatment (47%) or risk reduction (53%) (Figure 1). The average BMI was 24, and 6% were smokers. Procedures were performed utilizing inferolateral inframammary fold (IMF) (52%), superior or inferior periareolar (23%), lateral radial (10%), inferior radial (4%), or pre-existing scar (11%) incisions. Immediate breast reconstruction (n= 494, reconstruction rate 98.8%) was performed with direct-to-implant (DTI) (60%), tissue expander-implant (38%), or autologous (2%) reconstruction procedures. One reconstruction was delayed and 3 patients (5 breasts) declined reconstruction. Seventy percent had ADM-assisted reconstruction, 11% had mesh, and 19% had total or partial muscle coverage without ADM. Forty-three reconstructions had prior therapeutic radiation and 30 received postoperative radiation to the tissue expander (n=11) or implant (n=19). The nipple areola complex was partially or totally removed in 46 (9.2%) reconstructions due to ischemia (n=21), a positive cancer margin (n=19) or for symmetry (n=6).
Complications included infection (3.4%), skin necrosis (5.4%), partial or total nipple areola complex necrosis (4.2%), seroma (1.6%), and hematoma (1.6%) leading to implant loss in 1.8%. The number of breasts having one or more complications was 62 (12.4%) compared to 438 breasts (87.6%) with no complication. The complication rate was influenced by incision type with the inferolateral inframammary fold incision having the lowest complication rate (8.6%) and the periareolar incision having the highest complication rate (20.5%) (p<0.02 and p<0.004 respectively). There was a trend toward higher complication rates in patients with preoperative radiation and smokers, but this did not reach statistical significance. Smoking was associated with a higher rate of skin necrosis (17.2% vs. 4.7%), and the average implant volume in DTI reconstructions was higher in patients with a complication compared to without a complication (p<0.03 for each).
When comparing direct-to-implant and tissue-expander implant reconstructions, the inferolateral inframammary fold incision had significantly more direct-to-implant reconstructions (67.5%, p<0.03), while the inferior radial incision and smoking significantly decreased the number of direct-to-implant reconstructions (p<0.008).
A patient survey showed a preference for the inferolateral inframammary fold incision (75.4%) compared to periareolar (17.5%), inferior radial (5.3%), or lateral radial (1.8%).
Nipple-sparing mastectomy procedures have a high reconstructive rate and a low number of complications. The inferolateral inframammary fold incision offers a low complication rate, a high rate of direct-to-implant reconstructions, and is preferred by patients. Full thickness incisions around the areola increase complications and should be avoided.
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