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Expanding the Indications for Total Skin-Sparing Mastectomy: Is It Safe in Locally Advanced Disease?
Anne Warren Peled, MD, Frederick Wang, MD, Robert D. Foster, MD, Michael Alvarado, MD, Cheryl A. Ewing, MD, Laura J. Esserman, MD, MBA, Hani Sbitany, MD.
University of California, San Francisco, San Francisco, CA, USA.

PURPOSE:
Indications for total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex (NAC) skin continue to expand. Though initially used only for early stage breast cancer and for risk-reduction in high-risk patients, many centers now offer TSSM to patients with more advanced disease. However, despite this change in practice, limited outcomes data in this population have been reported.
METHODS:
A retrospective review of a prospectively-collected database of all patients undergoing TSSM and immediate reconstruction from 2005 to 2013 was performed. Outcomes from patients with Stage IIb and Stage III cancer were included in the analysis. Primary outcomes included post-operative complications and the development of a local-regional recurrence.
RESULTS:
139 (18%) of 753 total patients presented with locally advanced disease. Reconstructions included 128 (92%) expander-implant reconstructions, 10 (7%) pedicled TRAM flaps and 1 (1%) DIEP flap. 77% had neoadjuvant chemotherapy, the rest had adjuvant systemic or hormonal therapy. 63% had post-mastectomy radiation therapy. Major complications included 1.4% NAC necrosis, 3.6% mastectomy skin flap necrosis, 11% implant loss, and 12% severe infection. Local tumor recurrence rate was 6.4% at a mean follow-up of 32.4 months. None of the recurrences occurred in preserved NAC skin.
CONCLUSIONS: TSSM can be safely performed in patients with locally advanced cancer, with acceptable complication rates despite high incidence of systemic and adjuvant therapy. Oncologic outcomes demonstrate local recurrence rates similar to those following skin-sparing mastectomy.


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