Publications12
source:
publisher: Elsevier Health Sciences
by: Scott L Spear; Catherine M Hannan

Introduction Nipple-sparing mastectomy (NSM), or subcutaneous mastectomy, combines a skin-sparing mastectomy with preservation of the nipple–areola complex (NAC), with the possibility of intraoperative pathological assessment of adjacent tissue. Immediate reconstruction after NSM may allow for a better cosmetic result for patients undergoing total mastectomy. However, because of the impossibility of removing all glandular and ductal tissue from beneath the NAC, the oncologic safety of this procedure continues to be questioned. Subcutaneous mastectomy for primary breast cancer or risk reduction has been described for several decades. In 1962, Freeman 1 pioneered this surgical procedure, but it was eventually discredited because of unclear selection criteria, poor cosmetic results, high rate of complications, and lingering questions about its oncologic safety or efficacy. For the majority of the 20th century, removal of the NAC complex has been a standard part of a mastectomy, despite the fact that the nipple is a relatively uncommon site for breast cancer to develop. 2 The most often observed neoplasia of the nipple is Paget's disease of the breast (intraepidermal tumor cells of the nipple), which remains an uncommon presentation of breast malignancy, accounting for 1–3% of all breast tumors. 3 Nipple involvement may also occur in association with ductal carcinoma in situ (DCIS) or invasive breast cancer in the breast parenchyma. Fortunately, however, carcinoma of the nipple is extremely rare. 2 Meanwhile, with the advent of screening protocols allowing for earlier breast cancer detection and therefore smaller tumors and lesser-stage cancers, it has become increasingly tempting to preserve more and more of the native breast skin, leading to the classic ‘skin-sparing mastectomy’. With ever-increasing expectations of improved cosmetic results from breast reconstruction, it wo

journal: Breast Diseases: A Year Book Quarterly
source:
publisher: Mosby, Inc.
by: E.S. Hwang; L.J. Esserman
date: January 1, 2006

The authors of this article have made an important contribution to the exciting current era in breast reconstruction by reporting their success with the inframammary incision technique for total skin-sparing mastectomy. The subcutaneous mastectomy, which was popular 20 to 30 years ago, produced cosmetically superior results because it preserved the outward appearance of the nipple and the areolar complex. However, subcutaneous mastectomy fell from favor because of concerns about cancer recurrence. Several groups have reported their experience with preserving the skin of the nipple-areolar complex while removing the underlying ductal tissue. In the present study, this procedure was done successfully for 24 of 28 patients with breast cancer. Expanders were used for reconstruction in all patients, and cosmesis was excellent. The authors' discussion of the oncologic appropriateness of this procedure was quite compelling. We recently reported our own experience with 64 total skin-sparing mastectomies performed by a variety of techniques. We used implants or autologous reconstruction depending on patient preference and body type. Only 2 patients who underwent the procedure (3%) were later found to have occult ductal carcinoma in situ that required resection of the nipple and areolar skin. We also have some experience with the inframammary incision approach, but we found exposure with this technique to be difficult. In our hands, the lateral radial incision was the most reliable approach in terms of preservation of the nipple-areolar complex. We have not seen any local recurrences, but our mean follow-up time has been short (less than 2 years). As always, patient selection is important in the early adoption of any new technique. Our group, for example, has also seen an increased rate of complications among women who smoke, as the authors reported in their series, so we generally discourage such women from preservation of the nipple-areolar complex. Furthermore, although BRCA mut

journal: European Journal of Surgical Oncology
source:
publisher: Elsevier Ltd
by: P. Mustonen; J. Lepistö; A. Papp; M. Berg; T. Pietiläinen; V. Kataja; M. Härmä
date: January 1, 2004

Abstract Aim. The aim of our study was to (1) examine the incidence of surgical complications, (2) determine the incidence of loco-regional recurrences and (3) examine the safety of saving the nipple–areola-complex after immediate breast reconstructions in breast cancer. Methods. Sixty-six immediate breast reconstructions were performed. Wide local excision (WLE), skin sparing mastectomy and subcutaneous mastectomy (SCM) were performed to 12, 20 and 34 patients, respectively. In all patients with WLE the reconstruction was performed with the latissimus dorsi (LD) miniflap. In other patients reconstructions were done with a free TRAM-flap ( n=26), LD-flap ( n=27) or with a prosthesis only ( n=1). Results. Major flap necrosis developed in four patients. Local recurrence rate was 8.3% in the group where nipple–areola-complex was removed and 7.1% in the group where nipple–areola-complex was saved. Metastases were found in 12.5 and 0%, respectively. Conclusion. SCM compared to skin sparing mastectomy may lead to an enhanced risk of immediate surgical complications, but does not threat the oncological safety. Saving the nipple–areola-complex in immediate breast reconstructions is possible in early breast cancer, if the tumour is not in the central part of the breast.

source:
publisher: Elsevier Ltd
by: Kerry Davies; Lyra Allan; Paul Roblin; David Ross; Jian Farhadi
date: January 1, 2011

Abstract Skin sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) is not only oncologically safe but provides also significant benefits both cosmetically and functionally. The superiority of this technique can only be fully established, however, by developing a framework for minimising complications. The present study seeks to elucidate the key factors affecting outcome. Methods Data for all skin sparing mastectomies with immediate autologous and implant based reconstructions, performed in a three year period (2006–2008) was retrospectively collated. Complications were classified into major and minor. Patients were excluded who had flap loss due to vascular complications. Results The total number analysed was 151. 17.2% had major complications, 23% had minor and 61% had no complications. The Wise and the “tennis” incision had significantly higher rates of wound dehiscence when compared with the periareolar incision ( p = 0.025, p = 0.098). There was no significant difference between diathermy or blade dissection techniques, or the use of subcutaneous adrenaline infiltration. Increasing BMI was associated with increased skin flap necrosis and wound dehiscence, and an excised breast mass of greater than 750 g and a sternal notch to nipple length of greater than 26 cm are associated as well with increased flap-related complications ( p = 0.0002, p = 0.0049). Conclusion Factors such as Wise pattern and tennis racquet incision, BMI and breast mass and sternal notch to nipple length adversely affect skin sparing mastectomy flap morbidity. These factors should be factored in to patient selection and operative planning especially for obese and large breasted women undergoing skin sparing mastectomy with immediate breast reconstruction.

journal: Breast Diseases: A Year Book Quarterly
source:
publisher: Mosby, Inc.
by: Bridget A. Oppong; Virgilio Sacchini

The Evolution of Mastectomy Techniques Randomized trials, such as the National Surgical Adjuvant Breast and Bowel Project B-04 and B-06 clinical trials,1,2 provided a foundation for a minimally invasive approach to the surgical management of early breast cancers. Data from these trials resulted in women being offered breast conservation surgery rather than mastectomy. However, there will always be women who are not candidates for conservation surgery or who simply prefer mastectomy. For such patients, the surgical approach to mastectomy has shifted from the disfiguring radical mastectomy of old to skin-sparing mastectomy. Out of the skin-sparing technique evolved the subcutaneous mastectomy, described by Freeman in 1962.3 Today, the nipple-sparing mastectomy (NSM), as subcutaneous mastectomy is now called, offers an even better cosmetic outcome and has garnered much attention as mastectomy rates overall continue to increase in many parts of the United States.4 However, the question remains: Does NSM adequately accomplish the goal of mastectomy, which is to remove the entire mammary gland for maximum therapeutic benefit for those with cancer or prophylaxis for those at risk? Prophylactic Surgery Historically, it has been reported that bilateral prophylactic mastectomy (BPM) results in an approximately 90% reduction in the risk of developing subsequent cancer.5 This figure was based on a retrospective analysis of 639 women with a family history of breast cancer undergoing BPMs between 1960 and 1993. The current standard of care for prophylactic mastectomy is total mastectomy (with or without reconstruction) performed in the same way as a therapeutic mastectomy. In this well-known Mayo Clinic report, there was no significant difference in outcomes based on whether the mastectomy included the nipple or not.5 This provided some early assurance of the safety of non-standard mastectomy techniques, including NSM, for surgical prophylaxis. At Memorial Sloan-Kettering Cancer Center (MSKC

journal: Journal of Plastic, Reconstructive & Aesthetic Surgery
source:
publisher: Elsevier Ltd
by: Francesca De Lorenzi; Mario Rietjens; Massimo Soresina; Fabio Rossetto; Riccardo Bosco; Anna Rita Vento; Simonetta Monti; Jean Y. Petit
date: January 1, 2010

Summary Background In the last few decades, breast reconstruction often has not been offered to the elderly population due to the reluctance of clinicians concerned about serious co-morbidities. This study aims to demonstrate that breast reconstruction is feasible and safe in the elderly cohort. Methods Between 1999 and 2004, 63 elderly patients underwent an immediate reconstruction after breast cancer treatment at the European Institute of Oncology. A conservative treatment, combined with breast repair by plastic surgical techniques, was performed in 14 patients. In the remaining 49 patients, a modified radical mastectomy was necessary in 30 breasts, a total mastectomy in 19, a subcutaneous mastectomy in one case and a radical mastectomy in one patient. Three nipple-sparing mastectomies, along with intra-operative radiotherapy, were performed in two patients. A definitive silicone implant was used in 41 breasts and a skin expander in eight cases. A latissimus dorsi flap was performed in two patients, a pedicled transverse rectus abdominis muscle (TRAM) flap in two cases and a local advancement fasciocutaneous flap in another two patients. Results In all patients, surgery was well tolerated despite patient age. No systemic and medically unfavourable events occurred in the immediate and late postoperative period. Infection occurred in four patients (6.34%) and partial necrosis of the mastectomy flaps in three cases (5.5% of the mastectomies). Capsular contracture grade III and IV was reported in four cases (8.89%). Total implant removal was rated 12.24%, due to infection (three prostheses), exposure (one expander) and capsular contracture grade IV (two implants). Conclusions Implant-based technique of breast reconstruction should be made available to the elderly population.

journal: Journal of the American College of Surgeons
source:
publisher: Elsevier Inc.
date: January 1, 2011

Dr Kirby Bland (Birmingham, AL) It is a pleasure to discuss this paper, whose senior author, Dr Klimberg, is one of my former residents at the University of Florida. In this presentation by Dr Klimberg, we see an evolving concept objectively evaluated, which is very important to progress in this organ site cancer, the most common in women. However, it is unfortunate that total glandular mastectomy techniques, with axillary dissection (eg, modified radical mastectomy) and without axillary lymph node dissection (eg, total [or simple] mastectomy), followed by immediate reconstruction in which skin preservation is a prominent feature of the mastectomy, have received little attention in general surgery and surgical oncology. It should be stated up front, however, that resection of the previous biopsy scar and wound cavity en bloc with skin that overlies the neoplasm, together with the entire breast parenchymal contents, are cardinal technical caveats of the skin-sparing mastectomy. This is not a subcutaneous reconstruction. Dr Boneti, Dr Klimberg, and colleagues, however, bring an additional consideration to the surgical oncologist and plastic reconstruction surgeon: A surgical technique thought to be highly skeptical in its genesis that may have significant application for cosmetic reconstruction after the skin-sparing mastectomy. The approach of the authors, with which I also agree, is to remove remnants of any occult disease to reduce local regional occurrence by complete removal of all glandular nipple-areola complex (NAC), thereby leaving this intact with overlying skin. As you have heard described, this technique completely denudes all glandular tissue down to approximately 7 mm from the skin surface, which leaves only denuded skin of the areola, increasing the likelihood of ischemia with injury to the dermal vascular plexus. The literature is replete with reports that indicate between 5% and 40% of patients have residua

journal: European Journal of Surgical Oncology
source:
publisher: Elsevier Ltd
by: P. Poortmans

1. Introduction: Postmastectomy radiation therapy (PMRT) improves disease free and overall survival in breast cancer patients with risk factors. The number of women that wants breast reconstruction after mastectomy increases. Breast reconstruction can be done using implanted material, autologous tissue or a combination of both. 2. Radiation therapy after reconstruction: Immediate breast reconstruction (IBR) is becoming more popular for breast cancer patients that are not good candidates for breast conserving therapy. This has also led to the introduction of techniques that facilitate later reconstruction, including skin-sparing and nipple-areola complex sparing mastectomies. Uncertainty exists about the preferred type of IBR in patients that require PMRT to minimise the complication and reoperation rates and optimise the cosmetic outcome. Other concerns are the safety and efficacy of IBR -especially in patients with advanced breast cancer-, the possible risk of a delay in starting adjuvant systemic treatment and the influence on the quality of RT delivery. In general, PMRT is associated with a higher rate of capsular contracture following IBR using an implant. However, good results can be obtained in a majority of those patients. The use of a deflated tissue expander during PMRT after skin-preserving mastectomy is proposed to increase the chances for a successful reconstruction using implants by leaving the spared skin slightly expanded and to improve the anatomical conditions for delivering PMRT *thereby decreasing the risk of skin changes and subcutaneous fibrosis. Less data exist on PMRT following IBR using autologous tissue. Most authors report that the outcome in terms of complication rates and cosmetic results is better after autologous tissue reconstruction with or without an implant compared to implant reconstruction only. PMRT seems to have no or little influence on outcome after autologous tissue IBR. Surgical intervention, including free fat grafting, can be used to imp

journal: European Journal of Surgical Oncology
source:
publisher: Elsevier Ltd
by: M. Minafra; C. Punzo; A. Borzacchini

[email protected] Skin-sparing mastectomy, though being a demolitive surgery, is indicated in particular situations of oncological surgery and suggested for both its radicality and aesthetic outcome, as it still makes the role of mastectomy valid. The Authors studied a group of 90 patients affected by breast cancer who underwent primary surgery, from January 2010 to December 2011. Twenty-five more patients were selected within the group and treated with subcutaneous mastectomy (skin-sparing, SSM, or nipple-skin- sparing, NSM) followed by immediate reconstruction. Age, T, type of surgery and biopsy of the Sentinel Lymph-node and/or Lymphadenectomy were evaluated. Follow-up was considered between 36 and 15 months. Average age of the subgroup of 25 patients is 47.74 years. Seven patients had unifocal neoplasia, 18 had multifocal/multicentric neoplasia, while in all other cases the interested area was > than 2 cm. In all patients, imaging showed a neoplasia/NAC distance of at least 2 cm, with a pre-surgery diagnosis confirmed by microhistology and cytology. There was no randomization. In all cases, NAC intra-surgery histology was performed, which influenced the choice between NSM or SSM, considering the risk of local relapse as indicated in literature. The type of cut was imposed by the location of neoplasm and breast size. In 9 cases, mastectomy was followed by BLS, followed in turn in 3 cases by lymphadenectomy, due to LS positivity. In 15 patients, lymphadenectomy was performed at the same time as mastectomy in presence of positive N clinic. In 1 case, NSM was performed in 1 patient already subjected to QUART+lymphadenectomy, with a 25-year relapse. NSM/SSM was followed by immediate reconstruction with temporary expander. In 2 cases, nipple necrosis was observed after NSM, calling for successive NAC removal. A 36-to-15-month follow-up did not show local relapses (LR), nor distant recurrence of the pathology. The study evaluated the limits and advantages of the application of

journal: European Journal of Cancer
source:
publisher: Elsevier Ltd
by: S. Paepke; E. Klein; J. Ettl; M. Niemeyer; H. Bronger; D. Paepke; M. Kiechle

S212 Friday, 23 March 2012 Poster Sessions (LD) miniflap while modified radical mastectomy, skin sparing mastectomy and subcutaneous mastectomy were done in 2(5%), 4(10%) and 6(15%) patients respectively with complete reconstruction by extended(LD) flap. The complication rates were noted as follows: partial flap necrosis in 4 patients (10%), wound breakdown in 2 patients (5%), lymphorrhea in 2 patients (5%), seroma in 6 patients (15%), some of patients showed a minor deformity in the back which disappeared with time and most patients had temporary limitation of shoulder movements postoperatively but all recovered completely within few weeks. No patients underwent secondary nipple and areola reconstruction. No local recurrence or distant metastasis in any patient during the follow up period of our study. Evaluation of aesthetic results by patients revealed that 30 patients (75%) were deeply satisfied, 6 patients (15%) were satisfied and 4 patients (10%) were poorly satisfied. While, surgeon aesthetic evaluation was good in 28 patients (70%), satisfactory in 8 patients (20%) and fair in 4 patients (10%). Conclusion: (LD) flap breast reconstruction is a very versatile, safe and satisfactory technique with a success rate of over 99% and is even suitable for high-risk patients. Donor site seroma is the most common complication and can be treated by repeated aspiration in outpatient clinic. Latissimus dorsi (LD) miniflap is the mainstay of breast reconstruction after partial mastectomy to repair defects in the lateral quadrants and the upper inner pole with low donor site morbidity and deep patient satisfaction. 572 Poster Do Surgeons See Benefit of Operating in Stage IV Breast Cancer? A. Chaudhry 1 , Z. Rayter 1 . 1 Bristol Royal Infirmary, Breast Surgery, Bristol, United Kingdom Introduction: Historically, patients with established Stage IV disease have been referred for primary palliative management with surgery usually limited to locoregional control. Survival with metastatic breast cancer has improved

journal: European Journal of Cancer
source:
publisher: Elsevier Ltd
by: S. Paepke; S. Dittmer; A. Rezai; E. Klein; M. Kiechle

S212 Friday, 23 March 2012 Poster Sessions (LD) miniflap while modified radical mastectomy, skin sparing mastectomy and subcutaneous mastectomy were done in 2(5%), 4(10%) and 6(15%) patients respectively with complete reconstruction by extended(LD) flap. The complication rates were noted as follows: partial flap necrosis in 4 patients (10%), wound breakdown in 2 patients (5%), lymphorrhea in 2 patients (5%), seroma in 6 patients (15%), some of patients showed a minor deformity in the back which disappeared with time and most patients had temporary limitation of shoulder movements postoperatively but all recovered completely within few weeks. No patients underwent secondary nipple and areola reconstruction. No local recurrence or distant metastasis in any patient during the follow up period of our study. Evaluation of aesthetic results by patients revealed that 30 patients (75%) were deeply satisfied, 6 patients (15%) were satisfied and 4 patients (10%) were poorly satisfied. While, surgeon aesthetic evaluation was good in 28 patients (70%), satisfactory in 8 patients (20%) and fair in 4 patients (10%). Conclusion: (LD) flap breast reconstruction is a very versatile, safe and satisfactory technique with a success rate of over 99% and is even suitable for high-risk patients. Donor site seroma is the most common complication and can be treated by repeated aspiration in outpatient clinic. Latissimus dorsi (LD) miniflap is the mainstay of breast reconstruction after partial mastectomy to repair defects in the lateral quadrants and the upper inner pole with low donor site morbidity and deep patient satisfaction. 572 Poster Do Surgeons See Benefit of Operating in Stage IV Breast Cancer? A. Chaudhry 1 , Z. Rayter 1 . 1 Bristol Royal Infirmary, Breast Surgery, Bristol, United Kingdom Introduction: Historically, patients with established Stage IV disease have been referred for primary palliative management with surgery usually limited to locoregional control. Survival with metastatic breast cancer has improved

journal: European Journal of Cancer
source:
publisher: Elsevier Ltd
by: A. Chaudhry; Z. Rayter

S212 Friday, 23 March 2012 Poster Sessions (LD) miniflap while modified radical mastectomy, skin sparing mastectomy and subcutaneous mastectomy were done in 2(5%), 4(10%) and 6(15%) patients respectively with complete reconstruction by extended(LD) flap. The complication rates were noted as follows: partial flap necrosis in 4 patients (10%), wound breakdown in 2 patients (5%), lymphorrhea in 2 patients (5%), seroma in 6 patients (15%), some of patients showed a minor deformity in the back which disappeared with time and most patients had temporary limitation of shoulder movements postoperatively but all recovered completely within few weeks. No patients underwent secondary nipple and areola reconstruction. No local recurrence or distant metastasis in any patient during the follow up period of our study. Evaluation of aesthetic results by patients revealed that 30 patients (75%) were deeply satisfied, 6 patients (15%) were satisfied and 4 patients (10%) were poorly satisfied. While, surgeon aesthetic evaluation was good in 28 patients (70%), satisfactory in 8 patients (20%) and fair in 4 patients (10%). Conclusion: (LD) flap breast reconstruction is a very versatile, safe and satisfactory technique with a success rate of over 99% and is even suitable for high-risk patients. Donor site seroma is the most common complication and can be treated by repeated aspiration in outpatient clinic. Latissimus dorsi (LD) miniflap is the mainstay of breast reconstruction after partial mastectomy to repair defects in the lateral quadrants and the upper inner pole with low donor site morbidity and deep patient satisfaction. 572 Poster Do Surgeons See Benefit of Operating in Stage IV Breast Cancer? A. Chaudhry 1 , Z. Rayter 1 . 1 Bristol Royal Infirmary, Breast Surgery, Bristol, United Kingdom Introduction: Historically, patients with established Stage IV disease have been referred for primary palliative management with surgery usually limited to locoregional control. Survival with metastatic breast cancer has improved

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