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Nipple-sparing mastectomy in women with large or ptotic breasts
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e754ee755
CORRESPONDENCE AND COMMUNICATION Nipple-sparing mastectomy in women with large or ptotic breasts Nipple-sparing mastectomy has been shown to have equivalent oncological outcome to skin-sparing mastectomy in carefully selected patients and acceptable rates of nipple necrosis.1 Its role in risk-reducing mastectomy is established. However, it is widely considered that nipple-sparing mastectomy is only suitable for women with small and non-ptotic breasts. The reasons cited are that an excessive skin envelope may result in higher rates of nipple necrosis or in nipples that are poorly positioned on the reconstructed breast mound. A malpositioned, preserved nipple may result in a significant aesthetic compromise compared with a correctly positioned reconstructed nipple. Skin-reducing mastectomy utilising a Wise pattern approach has been described for women undergoing immediate implant reconstruction.2,3 It is most suitable for women with ptotic or large breasts who can accommodate a mastopexy or reduction and are willing to consider contralateral symmetrising surgery. We report a modification of the skin-reducing mastectomy to allow preservation of the nipple in women who would not otherwise be considered for this technique because of unsuitable breast shape.
Technique The pre-operative markings are as for a skin-reducing mastectomy: the proposed superior edge of the areola is marked and two lines are dropped to surround the nipple areola complex. Medial and lateral limbs are marked to meet the inframammary crease (Figure 1). Measurements are taken to ensure that closure will not be under tension at the T-junction. At surgery, the lower pole and skin around the nippleareola complex is de-epithelialized. The circumareolar incision is superficial and the superior and inferior skin-flaps are raised with particular care to preserve the subdermal vascular plexus upon which the nipple blood supply depends. Nipple core tissue is sent for frozen section to exclude unexpected disease. Mastectomy is completed in the usual fashion; the incisions provide good access for
oncological surgery. A sub-pectoral pocket is then developed, beginning 1 cm medial to the lateral border to facilitate later development of the sub-serratus lateral pocket. Pectoralis major is freed from its inferior attachments to the anterior chest wall. The transverse base width is measured to guide implant selection. The inferior and lateral borders of pectoralis major are sutured with interrupted sutures to the de-epithelialised inferior skin flap ‘dermal sling’ that was prepared earlier. Laterally, the dermal sling overlaps serratus to a variable extent. The tissue expander is inserted at this stage and adjusted according to pocket shape and skin flaps. Drains are inserted in the sub-pectoral and mastectomy cavities. The medial and lateral skin flaps are brought down to the inframammary crease and this incision is closed. The areola position is then confirmed and space created by deepithelialising a circle into which to insert the nipple-areola complex on its pedicle. Finally, the nipple to inframammary crease distance is shortened (typically to 5e8 cm) during closure of the vertical incision. Tissue expansion proceeds as for skin-sparing mastectomy, providing a pleasing breast shape with good projection and clear definition of the inframammary crease (Figure 2).
Results Seventeen breast reconstructions have been performed using this technique in eleven patients. Median patient age was 42 (range 35e49 years). All mastectomies were performed for risk-reduction and none demonstrated unexpected disease. Either Allergan 150 permanent biodimensional tissue expander implants or 133 biodimensional tissue expanders were used (Allergan Inc, Marlow, UK). In one patient, the vascularity of the retained nipple on the de-epithelialised superior flap on one side was deemed inadequate and the nipple was not preserved. The contralateral nipple was preserved with a satisfactory outcome. The patient who had the Allergan 133 tissue expander subsequently underwent exchange for a fixed volume biodimensional silicone implant. One patient developed unilateral nipple necrosis which was managed conservatively with an acceptable result. After a median of 9 months of follow up, all patients have retained good nipple symmetry and position in relation to the new breast mound and to the contralateral breast.
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.06.002
Correspondence and communication
Figure 1 Pre-operative marking with patient’s arms up to show planned skin reduction.
e755 studies that demonstrate oncological equivalence as well as psychological benefit.1 Patients must be selected for appropriate breast size, adequate chest wall elasticity to allow tissue expansion and good microcirculation to the skin. We have not applied this technique to patients who are smokers, have diabetes, or have had previous radiotherapy or surgery to the nipple. Several case series of nipple-sparing mastectomy report poor nipple symmetry in bilateral cases.4 It is likely that a small amount of fluid collecting between mastectomy skin flaps and reconstruction allows the preserved skin to redrape over the breast mound to a variable and uncontrolled extent. By reducing the skin envelope, such that it is closer to the breast mound size, relative movement is reduced and nipple position is controlled. We have not experienced problems with symmetry in bilateral cases using this technique.
Conflict of interests This work was not supported by any funding. Neither of the authors has any financial interest in the work, nor in the implants mentioned in the manuscript. Neither author has any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this manuscript.
References
Figure 2
Post-operative result, 1 month after surgery.
Discussion With improving survival following breast cancer treatment, there is an increasing expectation of a good aesthetic result following mastectomy in addition to oncologic disease control. Recent innovations towards nipple-sparing mastectomy have been driven by patient demand and
1. Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg 2010 Mar;97:305e16. 2. della Rovere GQ, Nava M, Bonomi R, et al. Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants. J Plast Reconstr Aesthet Surg 2008 Nov;61:1303e8. 3. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skinsparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002 Jul;110:206e11. 4. Denewer A, Farouk O. Can nipple-sparing mastectomy and immediate breast reconstruction with modified extended latissimus dorsi muscular flap improve the cosmetic and functional outcome among patients with breast carcinoma? World J Surg 2007 Jun;31:1169e77.
Jennifer E. Rusby Gerald P.H. Gui Academic Breast Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION Nipple-sparing mastectomy in women with large or ptotic breasts Nipple-sparing mastectomy has been shown to have equivalent oncological outcome to skin-sparing mastectomy in carefully selected patients and acceptable rates of nipple necrosis.1 Its role in risk-reducing mastectomy is established. However, it is widely considered that nipple-sparing mastectomy is only suitable for women with small and non-ptotic breasts. The reasons cited are that an excessive skin envelope may result in higher rates of nipple necrosis or in nipples that are poorly positioned on the reconstructed breast mound. A malpositioned, preserved nipple may result in a significant aesthetic compromise compared with a correctly positioned reconstructed nipple. Skin-reducing mastectomy utilising a Wise pattern approach has been described for women undergoing immediate implant reconstruction.2,3 It is most suitable for women with ptotic or large breasts who can accommodate a mastopexy or reduction and are willing to consider contralateral symmetrising surgery. We report a modification of the skin-reducing mastectomy to allow preservation of the nipple in women who would not otherwise be considered for this technique because of unsuitable breast shape.
Technique The pre-operative markings are as for a skin-reducing mastectomy: the proposed superior edge of the areola is marked and two lines are dropped to surround the nipple areola complex. Medial and lateral limbs are marked to meet the inframammary crease (Figure 1). Measurements are taken to ensure that closure will not be under tension at the T-junction. At surgery, the lower pole and skin around the nippleareola complex is de-epithelialized. The circumareolar incision is superficial and the superior and inferior skin-flaps are raised with particular care to preserve the subdermal vascular plexus upon which the nipple blood supply depends. Nipple core tissue is sent for frozen section to exclude unexpected disease. Mastectomy is completed in the usual fashion; the incisions provide good access for
oncological surgery. A sub-pectoral pocket is then developed, beginning 1 cm medial to the lateral border to facilitate later development of the sub-serratus lateral pocket. Pectoralis major is freed from its inferior attachments to the anterior chest wall. The transverse base width is measured to guide implant selection. The inferior and lateral borders of pectoralis major are sutured with interrupted sutures to the de-epithelialised inferior skin flap ‘dermal sling’ that was prepared earlier. Laterally, the dermal sling overlaps serratus to a variable extent. The tissue expander is inserted at this stage and adjusted according to pocket shape and skin flaps. Drains are inserted in the sub-pectoral and mastectomy cavities. The medial and lateral skin flaps are brought down to the inframammary crease and this incision is closed. The areola position is then confirmed and space created by deepithelialising a circle into which to insert the nipple-areola complex on its pedicle. Finally, the nipple to inframammary crease distance is shortened (typically to 5e8 cm) during closure of the vertical incision. Tissue expansion proceeds as for skin-sparing mastectomy, providing a pleasing breast shape with good projection and clear definition of the inframammary crease (Figure 2).
Results Seventeen breast reconstructions have been performed using this technique in eleven patients. Median patient age was 42 (range 35e49 years). All mastectomies were performed for risk-reduction and none demonstrated unexpected disease. Either Allergan 150 permanent biodimensional tissue expander implants or 133 biodimensional tissue expanders were used (Allergan Inc, Marlow, UK). In one patient, the vascularity of the retained nipple on the de-epithelialised superior flap on one side was deemed inadequate and the nipple was not preserved. The contralateral nipple was preserved with a satisfactory outcome. The patient who had the Allergan 133 tissue expander subsequently underwent exchange for a fixed volume biodimensional silicone implant. One patient developed unilateral nipple necrosis which was managed conservatively with an acceptable result. After a median of 9 months of follow up, all patients have retained good nipple symmetry and position in relation to the new breast mound and to the contralateral breast.
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.06.002
Correspondence and communication
Figure 1 Pre-operative marking with patient’s arms up to show planned skin reduction.
e755 studies that demonstrate oncological equivalence as well as psychological benefit.1 Patients must be selected for appropriate breast size, adequate chest wall elasticity to allow tissue expansion and good microcirculation to the skin. We have not applied this technique to patients who are smokers, have diabetes, or have had previous radiotherapy or surgery to the nipple. Several case series of nipple-sparing mastectomy report poor nipple symmetry in bilateral cases.4 It is likely that a small amount of fluid collecting between mastectomy skin flaps and reconstruction allows the preserved skin to redrape over the breast mound to a variable and uncontrolled extent. By reducing the skin envelope, such that it is closer to the breast mound size, relative movement is reduced and nipple position is controlled. We have not experienced problems with symmetry in bilateral cases using this technique.
Conflict of interests This work was not supported by any funding. Neither of the authors has any financial interest in the work, nor in the implants mentioned in the manuscript. Neither author has any commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this manuscript.
References
Figure 2
Post-operative result, 1 month after surgery.
Discussion With improving survival following breast cancer treatment, there is an increasing expectation of a good aesthetic result following mastectomy in addition to oncologic disease control. Recent innovations towards nipple-sparing mastectomy have been driven by patient demand and
1. Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg 2010 Mar;97:305e16. 2. della Rovere GQ, Nava M, Bonomi R, et al. Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants. J Plast Reconstr Aesthet Surg 2008 Nov;61:1303e8. 3. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skinsparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002 Jul;110:206e11. 4. Denewer A, Farouk O. Can nipple-sparing mastectomy and immediate breast reconstruction with modified extended latissimus dorsi muscular flap improve the cosmetic and functional outcome among patients with breast carcinoma? World J Surg 2007 Jun;31:1169e77.
Jennifer E. Rusby Gerald P.H. Gui Academic Breast Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK E-mail address: [email protected]