Outcomes after Total Skin-sparing Mastectomy and Immediate Reconstruction in 657 Breasts

ABSTRACT Background. Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications. Methods. Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple-areolar complex (NAC) on pathologic analysis, and cancer recurrence. Results. TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9 %)], invasive cancer [301 breasts (45.8 %)], and prophylactic risk-reduction [245 breasts (37.3 %)]. A total of 210 patients (49 %) had neoadjuvant chemotherapy, 78 (18.2 %) had adjuvant chemotherapy, and 114 (26.7 %) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7 %) and invasive cancer in 9 breasts (1.4 %); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2 %) of partial nipple loss, 10 cases (1.5 %) of complete nipple loss, and 78 cases (11.9 %) of skin flap necrosis. Overall locoregional recurrence rate was 2 % (median follow-up 28 months), with a 2.4 % rate observed in the subset of patients with at least 3 years' follow-up (median 45 months). No NAC skin recurrences were observed. Conclusions. In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence. Mastectomy with complete preservation of the skin envelope has been developed as an extension of skin-sparing mastectomy to improve aesthetic and psychological outcomes for patients. Nipple-sparing, or total skin-sparing, mastectomy techniques entail complete removal of all breast tissue with excision of the nipple tissue while preserving the entire skin envelope. The technique of total skin-sparing mastectomy (TSSM) is differentiated from subcutaneous mastectomy in that minimal, if any, nipple tissue is left behind. However, as with the initial reaction to skin-sparing mastectomy, there is still significant concern that preservation of the nipple-areolar complex (NAC) skin may increase locoregional recurrence rates. Although this concern has limited the widespread adoption of the technique, the recent publication of several studies with longer follow-up describing recurrence rates similar to those after skin-sparing mastectomy demonstrate that the technique does not appear to jeopardize oncologic safety

Expanding Candidacy for Nipple-sparing Mastectomy in Women with Large or Ptotic Breasts: Staged Reconstruction Outcomes

Background:. Development of the nipple-sparing mastectomy (NSM) technique has dramatically improved breast reconstruction, and preservation of the nipple–areolar complex (NAC) positively influences patient satisfaction. However, women with large, ptotic breasts have historically not been candidates for NAC preservation due to impaired perfusion of the NAC leading to NAC loss. Although reduction mammoplasty has been reported as a strategy to increase candidacy for NSM, success rates and surgical outcomes for this staged approach are not well described in heterogeneous clinical scenarios. Methods:. We performed a retrospective chart review of all patients who underwent reduction mammoplasty followed by NSM at our institution between January 2014 and September 2020. Clinical and surgical characteristics were collected. All surgical complications, including NAC loss rates, were analyzed. Results:. Forty-one patients (74 breasts) underwent staged NSM during the defined time period. The average time between breast reduction mammoplasty and NSM was 213 days. Overall, 94.6% of NSM resulted in successful nipple preservation. There was no significant difference in the time interval from breast reduction mammoplasty to NSM between patients who had NAC loss (208 days) and those who did not (213 days, P = 0.87). Increasing age was significantly associated with risk of NAC loss (P = 0.002) in our cohort. Conclusions:. In women with breast ptosis (which precludes safe NSM), it is possible to first offer reduction mammoplasty to preserve the NAC for future NSM. Our data suggest that 3 months between staged procedures is a safe time frame