Nipple-sparing skin-reducing mastectomy with reconstruction for large ptotic breasts

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Nipple-sparing skin-reducing mastectomy with reconstruction for large ptotic breasts M. Kontos , S. Lanitis , A. Constantinidou , P. Sakarellos , E. Vagios , E.C. Tampaki , A. Tampakis , M. Fragoulis PII: DOI: Reference:

S1748-6815(19)30513-3 https://doi.org/10.1016/j.bjps.2019.11.025 PRAS 6329

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Journal of Plastic, Reconstructive & Aesthetic Surgery

Received date: Accepted date:

24 May 2019 22 November 2019

Please cite this article as: M. Kontos , S. Lanitis , A. Constantinidou , P. Sakarellos , E. Vagios , E.C. Tampaki , A. Tampakis , M. Fragoulis , Nipple-sparing skin-reducing mastectomy with reconstruction for large ptotic breasts, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.11.025

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Nipple-sparing skin-reducing mastectomy with reconstruction for large ptotic breasts Kontos M, Lanitis S, Constantinidou A, Sakarellos P, Vagios E, Tampaki EC, Tampakis A, Fragoulis M 1st Department of Surgery, National and Kapodistrian University of Athens, Laiko Hospital Corresponding author: Michael Kontos, 1st Department of Surgery, National and Kapodistrian University of Athens, Laiko Hospital, 27 Agiou Thoma Street, 11527 Athens, Greece. Tel +302132061001; Fax +302132061766. The present work has not been presented in any meeting Summary Background: Breast reconstruction is routinely used to alleviate the psychological adverse effects of mastectomy. Nipple preservation further improves the cosmetic result and causes less trauma on the body surface. Nipple sparing mastectomy, however, comes with challenges, especially in the case of large, ptotic breasts to the degree that large sized breasts have conventionally been a contra-indication for nipple preservation. In this report we describe a novel technique for nipple preservation in immediate reconstruction of large, ptotic breasts. Methods: From 2013 to 2018 24 patients (30 breasts) with large, ptotic breasts were treated with mastectomy and immediate reconstruction with nipple preservation. Median BMI was 28 and eight patients were smokers. The technique involves the de-epithelialisation of a large area of the breast skin, the mastectomy through a lateral full-thickness incision within the deepithelialised area, imbrication of the de-epithelialised skin, lifting of the nipple to a higher position and finally closure of wound. Results: There were no full and four partial nipple necroses and three re-operations were done under local anaesthetic to correct partial peripheral necrosis of the areola. Six patients needed seroma aspiration and four presented with cellulitis. No implants were lost and there were no delays to adjuvant treatment. Conclusions: The proposed technique has significant advantages and may be ideal when large skin reductions are necessary in immediate breast reconstruction with nipple 1

preservation. The low complication rate makes the method ideal when adjuvant treatment is to follow and/or patients are of high risk for surgical complications.

Keywords Breast reconstruction; skin reducing mastectomy; nipple sparing; nipple ischaemia; complications Introduction Mastectomy remains widely in use for the treatment of breast cancer as well as a breast cancer risk reducing measure. Breast reconstruction is used to alleviate the adverse effect this procedure has on patients’ quality of life and several techniques have been proposed. With the increase of experience and better understanding of tumour biology we have moved towards better reconstructions and more conservative mastectomies, namely skin or even nipple preserving. These are supposed to cause less trauma on the body surface and leave easier-to-hide scars. The preservation of the nipple is desirable by patients and has been proved to be oncologically safe in many cases (1, 2). However, despite the obvious advantages, nipple sparing mastectomy (NSM) comes with challenges. Of them, the viability of the nipple areola complex (NAC) is the most serious one, since the underlying tissue which provides the blood supply to the NAC must be removed for oncological reasons and the NAC is therefore left dependent on the delicate vessels of the skin and subcutaneous tissue. A second limitation is that NSM is not for every breast size, even if oncology allows NAC preservation. Large, ptotic breasts have been regarded as a contraindication for NAC preservation due to the fear that the NAC will not survive the removal of the underlying supporting breast tissue and the excision of the excess skin which is often necessary (3). The aim of this study is to present our experience on a novel technique of NSM with synchronous reduction of the excess breast skin (nipple sparing/skin reducing mastectomy, NS/SRM) in patients with large ptotic breasts. Patients and Methods 2

From January 2013 to December 2018, 24 patients were treated with NS/SRM in our Department. Of them 15 received unilateral and eight bilateral treatment. In total 30 breasts were operated upon with this technique; one patient with bilateral therapeutic procedure had natural asymmetry and received NS/SRM on one side and routine NSM on the other. Patients who had their nipple removed for oncological reasons after the histological report was issued were excluded from this study. Patient and disease characteristics are presented in Table 1. The technique is as follows: With patient standing, the middle line of the chest, the meridian of the breast (mid clavicle to nipple) extending to the abdomen, the periphery of the NAC and the inframammary fold were routinely drawn. The new location of the centre of the NAC (A) was marked 19-21 cm from the sternal notch on the breast meridian. The upper half of the periphery of the NAC at the new location (a semi-circle) was then drawn (figure 1a). Then, about 8 cm from the inframammary fold on the breast meridian the new location of the centre of the NAC (B) was drawn again. The lower half of the periphery of the NAC at the new location (a semi-circle) was marked too (figure 1a). The distance of 8 cm refers to an average patient of 1.65 m in height and it can vary slightly depending on patient build. Radius of either semi-circle is 2-2.5 cm, so that they will jointly form a 4-5cm full circle that will host the new NAC. If further skin reduction is desired, the radius of either semi-circle can increase up to 3.75-4.75 cm; in these cases the small additional reduction is achieved through the purse string suturing of the periphery of the two semi-circles to the transposed NAC and plication to a final diameter of 4-5 cm. Then the most medial (C) and most lateral (D) points of the “footprint” of the breast on the chest wall were found and two curved lines were drawn freehand: one connecting the points C-A-D and the second the points C–B-D (figure 1b). Effort should be made so that the most medial and lateral points can be hidden in the brassiere.. In the operating theatre, the area between the two lines, including the two semicircles, with the exception of the NAC, is de-epithelialised (figure 1c). It is worth highlighting 3

that no actual excision of skin takes place, it is only the epidermis within the marked area removed, while the underlying layers of the skin are preserved. Then, a full-thickness incision is made at the outer part of the de-epithelialised area and the mastectomy is routinely performed through it (figure 1d). Special attention is given to the area under the NAC so that the procedure is oncologically radical with the least impact on NAC’s vasculature. Frozen section of this area can be used. The axillary procedure is performed through the same incision. The reconstruction then is carried out as per routine with the use of Acellular dermal matrix (ADM providing coverage to the lower part of the implant. We use tissue expanders which are filled with saline to at least the 50% of their capacity. If solid implants are directly used and in case of a partial NAC necrosis, after the surgical debridement the re-sutured healthy edges will be under tension, as they cannot be deflated. There were a few cases where we did not use an ADM, but the de-epithelialised skin was so abundant that was used for this purpose, especially if the anatomy of pectoralis major was favourable. At closure, the two semi-circles are brought together and the NAC is pulled through and sutured to its new location. Transient ischaemia or venous congestion of the NAC was not unusual at this point and if means of intraoperative blood supply detection are available, they can be used. The incisions on either side of the NAC are then closed with interrupted sutures to the de-epithelialised skin and with subcuticular sutures. The periphery of the NAC is sutured purse-string with a long-lasting suture so that it does not stretch with time. Results The results are shown in Table 2. Four of the 30 breasts in four patients suffered partial peripheral necrosis of the areola and in three of them a small surgical procedure was necessary to remove the necrotic tissue (Figures 2,3). In these cases the expander was slightly deflated and the wound was re-sutured with as little tension as possible. It is worth mentioning that NAC ischaemia or venous congestion was seen more often but it usually resolved spontaneously. It is advisable to wait until the ischaemic area is adequately demarcated before resorting to 4

surgical debridement. The NAC was lifted by 8 cm on average and no implant was lost in this group of patients. Discussion Mastectomy remains often necessary in the treatment of breast cancer as well as a breast cancer risk reducing measure. At the same time, the expectations of women who are planned to undergo the procedure regarding their body image have significantly raised during the last years. When mastectomy cannot be avoided or when desired, breast reconstruction is expected to ameliorate the effects of such a radical and visually noticeable surgical intervention and is usually offered at the time of oncological surgery. The preservation of the NAC takes breast reconstruction to the next level minimizing the losses due to surgical treatment, leaving a body image closer to natural and eliminating the signs reminiscent of cancer and its treatment. It is worth mentioning, however, that the preservation of the NAC is not always safe for oncological reasons; there are several reports attempting to determine the indications for NSM (4) and at least one large prospective ongoing registry for NSMs (5) aiming to define the relevant indications and contraindications, the optimal surgical techniques, the complications etc. But even when oncology allows, women with heavier breasts and significant ptosis are usually excluded from NAC conservation procedures because of the problem of excessive skin and NAC ischaemia after mastectomy with skin reduction. The preserved skin envelope – which bears the NAC - is usually too big for the implants commonly used (or the available autologous tissue in the cases of autologous reconstruction) and must be reduced; but skin excision further compromises blood supply to the NAC, which is already reduced due to the removal of the underlying breast tissue. In this report we present a novel technique which achieves NAC preservation with significant skin reduction with very little complications. The idea behind the procedure is that the excessive skin – and therefore its valuable vascular network crucial for the blood supply to the NAC - is not cut or removed, but simply de-epithelialised and then imbricated (folded underneath) under the mastectomy skin flaps. The de-epithelialised skin will only suffer a 5

lateral incision through which the removal of the actual breast tissue will take place. And since the majority of the blood supply to the NAC originates from the internal mammary tributaries, it is wise to make this incision at the lateral part of the de-epithelialised skin, in order to keep the vascular network intact. The reduction of the skin is achieved through the “shortening” along the vertical axis (breast meridian) which is usually the main issue with large and ptotic breasts (figure 1). With this technique the extent of vertical reduction is practically unlimited. The reduction along the horizontal axis is generally smaller and is achieved thanks to the difference between the diameter of the de-epithelialised semi-circles (where the NAC will be placed in its new position) and the actual diameter of the NAC and the subsequent pursue-string closure. In our experience hardly ever is there need for more radical skin reduction along the horizontal axis, especially when large sized implants are used. The technique is applicable when one-stage silicon based reconstruction is planned. We haven’t used it with autologous reconstruction. Furthermore, free NAC grafting is an alternative but bears all the disadvantages the technique has both in the short and long term. This presented technique of skin reducing NSM has certain advantages: 

The NAC preserves its blood supply from throughout its periphery.



There are only two skin flaps sutured along a line and around the

NAC; there is no such thing as “T junction”, notorious for delayed healing and ugly scar formation 

It is feasible in very large ptotic breasts as the skin reduction along the

meridian is practically unlimited. 

Fixed volume implants can be used directly (not here)

Disadvantages are: 

Long horizontal scar; this, however can be planned in a way that it

lays below the socially visible cleavage area. 

NAC ischaemia rare but not impossible

6



Often ADM (acellular dermal matrix) is needed to provide cover at the

lower part of the implant if the inwards folded de-epithelialised skin is not enough. 

Technically demanding as a procedure and when expanders are used,

difficult to locate the inflation valve because of the overlying folded de-epithelialised skin As the problem with NAC preservation in large ptotic breasts undergoing immediate breast reconstruction is long identified, there are several published articles reporting different techniques in the attempt to achieve preservation with minimal complications. Pontel et al (6) used a “boomerang” shaped supra-areolar full thickness incision through which the mammary gland and a “boomerang” shaped piece of skin was removed. Then the NAC was lifted and sutured higher on the breast meridian with consequent shortening of the vertical axis of the breast. The authors report rates of partial and total NAC necrosis of 12.5% and 18.7%, respectively. Shih et al (7) use a different approach where a wise pattern shaped part of skin is de-epithelialised and the breast is removed through a lateral radial incision. Then the de-epithelialised skin is folded underneath and the breast is reconstructed with an implant and ADM. The procedure, however, involved an additional surgical procedure where the NACs were devascularised bilaterally and subareolar biopsies were taken a few weeks earlier. A similar but one-stage technique has been reported by Rusby et al (8). A wisepattern shaped part of the skin is de-epithelialised and the mastectomy is performed through full-thickness incision on the de-epithelialised skin. Two cases with NAC ischaemia or necrosis are reported in 17 reconstructions. Miller et al (9) also used a wise-pattern technique where the skin around the NAC and at the lower pole was de-epithelialised and the mammary tissue was removed through a full thickness incision at the lower part of the breast. Out of 47 breasts in 30 patients, there were but 4% major complications but no NAC losses. Petchevy et al (10) use a wise-pattern or a vertical approach and the full thickness incision is vertical and located between the vertical limps of the pattern. In the cases where the NAC was preserved the reported NAC necroses were 20% and wound dehiscence 60%. 7

Perhaps the oldest published technique for NAC preservation with skin reduction in mastectomies is by Gibson (11) who base the NAC perfusion on an inferior dermal pedicle after a wise pattern type incision. Vrekoussis et al (12) report a similar technique in one of their patients. In an attempt to secure better blood supply to the NAC Todd et al (13) utilises a double pedicle (superior and inferior) after a wise pattern skin full thickness incision and reports a partial NAC necrosis about 15%. A similar superior-inferior technique is also used by Al-Mufarrej et al (14) who report four patients with NAC necrosis out of 24 with wise pattern mastopexy. In the same publication there is a small number of patients with smaller size breasts who underwent donut mastopexy with one case of areolar ischaemia in nine patients. Finally Rivolin et al (15) describe a type of donut mastopexy with a lateral radial incision, where the mastectomy is done through. The fact that there are several different techniques described for this purpose indicates that there is no unanimity on the optimal procedure for NAC preservation in large ptotic breasts. Depriving the NAC from its blood supply - due to mastectomy and/or excess skin excision - results in high rates of NAC ischaemia and necrosis. In a report a staged procedure was advocated to alleviate this. Furthermore, often in the described techniques the actual degree of skin reduction is mediocre; and finally when the classic “inverted T” procedure is utilised with the aim to increase the degree of skin reduction, the T junction results in delayed healing or dehiscence. NAC necrosis is not uncommon either with rates usually exceeding 10%. In the present study, there were four out of 30 reconstructions (13.3%) that required post-surgical attention due to NAC necrosis. This may look like a rather high complication rate but one should take into account the specific characteristics of this group of patients (smoking, obesity etc) as well as the challenges of the procedure. Furthermore, in the literature, reported complication rates in patients undergoing nipple preserving mastectomy with some type of skin reduction, are certainly comparable to ours and often higher, sometimes in more selected populations, as mentioned above [Pontel: partial and total nipple necrosis 12.5% and 18.7% respectively (6); Rusby: NAC ischaemia or necrosis 11.7% 8

(8); Miller: 4% major complications with no NAC losses (9); Petchevy: 20% NAC necrosis (10); Todd: NAC necrosis 15% (13); and Al-Mufarrej NAC necrosis 16.6% (14)]. The proposed technique has several pros and cons as highlighted above but may be ideal when large skin reductions are necessary. The low complication rate makes the method ideal, particularly when adjuvant treatment is to follow and cannot be delayed. Conflict of interest statement All authors declare NO CONFLICT OF INETEREST and received NO FUNDING for the present manuscript References 1. Wei CH, Scott AM, Price AN, et al. Psychosocial and Sexual Well-Being Following Nipple-Sparing Mastectomy and Reconstruction. Breast J 2016;22:10-7. 2. Huang J, Mo Q, Zhuang Y, et al. Oncological safety of nipple-sparing mastectomy in young patients with breast cancer compared with conventional mastectomy. Oncol Lett 2018;15:4813-20. 3. Spear SL, Hannan CM, Willey SC, Cocilovo C. Nipple-sparing mastectomy. Plast Reconstr Surg 2009;123:1665–73 4. Weber WP, Haug M, Kurzeder C, et al. Oncoplastic Breast Consortium consensus conference on nipple-sparing mastectomy. Breast Cancer Res Treat 2018;172:52337. 5. European Society of Surgical Oncology. International Nipple Sparing Mastectomy Registry. https://www.essoweb.org/eurecca-inspire/ [Accessibility verified May 21, 2019] 6. Pontell ME, Saad N, Brown A, Rose M, Ashinoff R, Saad A. Single stage nipplesparing mastectomy and reduction mastopexy in the ptotic breast. Plast Surg Int 2018;2018:9205805. 7. Shih HB, Shakir A, Wapnir IL, Nguyen DH. Concurrent skin reduction in nipple sparing mastectomy and immediate tissue expander reconstruction for grade three ptosis breasts. J Aesthet Reconstr Surg 2016;2:1-4. 9

8. Rusby JE, Gui GP. Nipple-sparing mastectomy in women with large or ptotic breasts. J Plast Reconstr Aesthet Surg 2010;63:e754-5. 9. Miller M, Fedele G, Dietz JR. Skin Reduction Nipple Sparing Mastectomy: Safe and feasible in large volume or ptotic breasts. 19th Annual Meeting. American Society of Breast Surgeons, Poster 403814. 10. Pechevy L, Carloni R, Guerid S, Vincent PL, Toussoun G, Delay E. Skin-reducing mastectomy in immediate reconstruction: How to limit complications and failures. Aesthet Surg J 2017;37:665-77. 11. Gibson EW. Subcutaneous mastectomy using an inferior nipple pedicle. ANZ J Surg 1979;49:559-60. 12. Vrekoussis T, Perabo M, Himsl I, Günthner-Biller M, Dian D. Bilateral prophylactic skin-reducing nipple-sparing mastectomy with immediate breast reconstruction using only a vascularized dermal-subcutaneous pedicle: technique and possible advantages. Arch Gynecol Obstet 2013;287:749-53. 13. Todd J. Wise-pattern skin reducing and nipple-sparing mastectomy using modified McKissock’s vertical bi-pedicle dermal flap in large breasted patients for immediate reconstruction and revision cases. Adv Plast Reconstr Surg 2018;207-14 14. Al-Mufarrej FM, Woods JE, Jacobson SR. Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction. J Plast Reconstr Aesthet Surg 2013;66:747-55. 15. Rivolin A, Kubatzki F, Marocco F, et al. Nipple-areola complex sparing mastectomy with periareolar pexy for breast cancer patients with moderately ptotic breasts. J Plast Reconstr Aesthet Surg 2012;65:296-303. Figure 1. Preoperative markings. a) A and B mark the centre of the new location of the NAC. b) two curved lines were drawn between the most medial (C) and most lateral (D) points of the “footprint” of the breast on the chest wall: one connecting the points C-A-D and the other the points C–B-D. c) The shaded area is de-epithelialised.d) The interrupted red line shows the full thickness incision within the de-epithelialised area through mastectomy takes place. 10

Line Ce is sutured to Cf and Dg to Dh. The forming circle will host the NAC at its new location. Figure 2. Before and after result of a bilateral prophylactic mastectomy with immediate reconstruction in a heavy breasted woman. Figure 3. Small partial peripheral necrosis of the areola can be easily corrected under local anaesthesia. Table 1. Patient and disease characteristics. Age, mean/median/range (y) 50.69/50/36-67 BMI

27.78/28/23-33

Smoking

8 pts or 11 breast reconstructions exposed to the risks of smoking

Previous radiotherapy for

6 patients / 7 breasts

breast cancer or Hodgkin’s lymphoma Comorbidities

Hypertension: 2 patients/3 breasts Diabetes: 2 patients/3 breasts Systematic Lupus Erythematosus: 1 patient / 1 breast

Purpose of surgery

Prophylactic 8/Therapeutic 22

(prophylactic/therapeutic) Table 2. Procedure characteristics, complications and oncological treatment. Distance of nipple lift,

8.13/8/6-10

mean/median/range (cm) Partial NAC necrosis

4 out of 30 breasts

NAC loss

0

Other complications

Seroma needing aspiration: 8 breasts in 6 patients

11

Cellulitis: 4 breasts in 4 patients (of whom 1 patient had both cellulitis and seroma) Wound dehiscence: 0 Reconstruction failure /

0

implant loss Need for reoperation in the

3 breasts in 3 patients due to partial NAC necrosis

first 2 postoperative months or until the end of adjuvant treatment Interval until commencement

37.81/39/29-49

of adjuvant treatment, mean/median/range (d) Tumour size at surgery (T),

21.25/22/7-39

mean median, range (mm) [of the patients where tumour was present at surgery] Nodal status at surgery (N)

Positive: 8 breasts Negative: 14 breasts

Neoadjuvant chemotherapy

8 patients

Adjuvant chemotherapy

11 patients

Adjuvant radiotherapy

11 patients

Adjuvant endocrine

18 patients

treatment

12

13

14

15

16

17