An Evolving Landscape: Return of Breast Sensation After Mastectomy Varies by Anatomic Region and Reconstructive Method.

PURPOSE: Loss of breast sensation after mastectomy has been well documented. Postoperative reinnervation of the breast is influenced by factors including reconstructive technique, patient comorbidities, and adjuvant treatment. However, little attention has been paid to the differences in sensation across regions of the breast and the impact of reconstructive method on these regional differences over time. METHODS: Patients undergoing nipple-sparing mastectomy with immediate autologous or alloplastic reconstruction were prospectively followed. Neurosensory testing was performed in 9 breast regions using a pressure-specified sensory device. Patients were stratified by reconstructive technique, and regional sensation was compared at different preoperative and postoperative time points using Student t tests. RESULTS: One hundred ninety-two patients were included; 106 underwent autologous reconstruction via neurotized deep inferior epigastric artery perforator flap, and 86 underwent 2-stage alloplastic reconstruction. Preoperative sensation thresholds did not differ between reconstructive cohorts in any region and averaged 18.1 g/mm2. In the first year after mastectomy, decreased sensation was most pronounced in the inner breast regions and at the nipple areolar complex (NAC) in both reconstructive cohorts. At 4 years postoperatively, sensation increased the most at the NAC in the alloplastic cohort (34.0 g/mm2 decrease) and at the outer lateral region in the autologous cohort (30.4 g/mm2 threshold decrease). The autologous cohort experienced improved sensation compared with the alloplastic cohort in 5 of 9 regions at 1 year postoperatively, and in 7 of 9 regions at 4 years postoperatively; notably, only sensation at the outer superior and outer medial regions did not differ significantly between cohorts at 4 years postoperatively. CONCLUSIONS: Although patients undergoing breast reconstruction experience increased breast sensation over time, the return of sensation is influenced by type of reconstruction and anatomic region. Regions closer to and at the NAC experience the greatest loss of sensation after mastectomy, although the NAC itself undergoes the most sensation recovery of any breast region in those with alloplastic reconstruction.Autologous reconstruction via a neurotized deep inferior epigastric artery perforator flap results in increased return of sensation compared with alloplastic reconstruction, particularly in the inferior and lateral quadrants of the breast.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy.

PURPOSE: Nipple-areolar complex (NAC) viability remains a significant concern following prepectoral tissue expander (TE) reconstruction after nipple-sparing mastectomy (NSM). This study assesses the impact of intraoperative TE fill on NAC necrosis and identifies strategies for mitigating this risk. METHODS: A chart review of all consecutive, prepectoral TEs placed immediately after NSM was performed between March 2017 and December 2022 at a single center. Demographics, mastectomy weight, intraoperative TE fill, and complications were extracted for all patients. Partial NAC necrosis was defined as any thickness of skin loss including part of the NAC, whereas total NAC necrosis was defined as full-thickness skin loss involving the entirety of the NAC. P < 0.05 was considered statistically significant. RESULTS: Forty-six patients (83 breasts) with an average follow-up of 22 months were included. Women were on average 46 years old, nonsmoker (98%), and nondiabetic (100%) and had a body mass index of 23 kg/m2. All reconstructions were performed immediately following prophylactic mastectomies in 49% and therapeutic mastectomies in 51% of cases. Three breasts (4%) were radiated, and 15 patients (33%) received chemotherapy. Mean mastectomy weight was 346 ± 274 g, median intraoperative TE fill was 150 ± 225 mL, and median final TE fill was 350 ± 170 mL. Partial NAC necrosis occurred in 7 breasts (8%), and there were zero instances of complete NAC necrosis. On univariate analysis, partial NAC necrosis was not associated with any patient demographic or operative characteristics, including intraoperative TE fill. In multivariable models controlling for age, body mass index, mastectomy weight, prior breast surgery, and intraoperative TE fill, partial NAC necrosis was associated with lower body mass index (odds ratio, 0.53; confidence interval [CI], 0.29-0.98; P < 0.05) and higher mastectomy weight (odds ratio, 1.1; CI, 1.01-1.20; P < 0.05). Prior breast surgery approached significance, as those breasts had a 19.4 times higher odds of partial NAC necrosis (95% CI, 0.88-427.6; P = 0.06). CONCLUSIONS: Nipple-areolar complex necrosis following prepectoral TE reconstruction is a rare but serious complication. In this study of 83 breasts, 7 (8%) developed partial NAC necrosis, and all but one were able to be salvaged.

The wide base bipedicled (WIBB) flap in nipple-sparing skin-reducing mastectomy.

In this article, we present a modification of the NS/SRM technique in which the mastopexy design for skin reduction is undertaken with a wide-base bipedicled (WIBB) flap. The WIBB flap can be applied in both autologous and implant-based breast reconstruction. Our reconstructive algorithm is also presented. The clinical data of patients operated on from June 2017 to November 2022 were collected: 51 patients for a total of 71 breasts. Personal data, BMI, type and volume of implants used, and major and minor complications were analyzed by descriptive statistics. The mean age was 48.3 years. BMI ranged between 21.5 and 30.9 kg/m2. Thirty-one patients underwent unilateral mastectomy, while twenty patients underwent bilateral surgery. In 25 breasts, immediate reconstruction was performed with implants and ADM. In 40 breasts, reconstruction was performed with a subpectoral tissue expander, and in 6 breasts, reconstruction was performed with a DIEP flap. We observed only one case (1.4%) of periprosthetic infection requiring implant removal under general anesthesia. Minor complications occurred in 14.1% of patients. The use of both the WIBB flap and our algorithm maintained a low complication rate in our series, ensuring oncological radicality and a good aesthetic result at the same time.

Evaluation of the Efficacy and Safety of Pedicled Perforator Flap Technique for Salvage Nipple Reconstruction in Breast Cancer Patients: A Pilot Study.

OBJECTIVE: We propose a pedicled perforator flap technique for salvage nipple reconstruction after initial nipple reconstruction fails in breast cancer patients. METHODS: This is a pilot study. A total of 21 female breast cancer patients who underwent nipple reconstruction following initial nipple reconstruction fails were enrolled, and salvage nipple reconstruction based pedicled perforator flap were performed between 2016 and 2020. Operative time, perforator design, postoperative complications, follow-up duration, projection of nipple, as well as patient-reported outcomes measured by the BREAST-Q and visual analogue scale (VAS) were assessed. RESULTS: Sixteen patients underwent fifth lateral intercostal artery perforator reconstruction, while 5 patients underwent fifth anterior intercostal artery perforator flap reconstruction. The surgeries were successful without intraoperative complications, with a mean operative time of 67 minutes. Postoperative complications were absent. The mean follow-up duration was 18 months. The mean nipple projection was 8 mm (range, 6-10 mm) with a shrinkage of 20% at 6 months after surgery. The average scores for psychosocial well-being, satisfaction with breasts, and satisfaction with nipples domains of the BREAST-Q significantly increased (P < .01) at 6 months post-reconstruction. Sexual well-being subdomain showed no statistical difference (P = .9369). The VAS scores for cosmesis and patient satisfaction with surgery were 9 and 9.3, respectively. CONCLUSION: The pedicled perforator flap technique for salvage nipple reconstruction is a safe and effective approach.

One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

A Scoping Review of Innervated Breast Reconstruction.

BACKGROUND: After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. RESULTS: From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. CONCLUSIONS: Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.

Direct neurotization of free nipple grafts with cadaveric nerve grafts following mastectomy for gender affirming surgery.

BACKGROUND: Free nipple grafting makes sensory recovery challenging. Permanent decreased sensation to touch and temperature in skin-grafted skin is common. Direct neurotization of the nipple-areolar complex (NAC) graft has been described. However, quantitative data regarding degree of nipple reinnervation possible is unknown. This study aims to quantify and qualify sensation recovery following nerve coaptation to reinnervate the NAC. METHODS: Patients undergoing mastectomy for gender dysphoria from 2020 to 2022 were offered nerve allograft to restore nipple sensation. A lateral intercostal nerve was selected and coapted to allograft which was embedded beneath the nipple graft. Semmes Weinstein testing was used to assess nipple sensation. Assessments were made at visits <1 year and >1 year from surgery. Filaments used represented normal sensation, minor diminished sensation, diminished sensation, loss of protective sensation, and deep pressure sensation only. RESULTS: A total of 115 patients elected for direct neurotization. Semmes Weinstein testing was limited to 46 patients representing 46 encounters and 92 nipples in the <1 year group and 24 encounters and 48 nipples in the >1 year group. Of the 92 nipples in the <1 year group, 17 (18.5%) noted return of normal sensation and 37 (40.2%) noted minor diminished or diminished sensation, indicating nerve reinnervation. There were 38 (41%) nipples with loss of protective sensation or deep sensation only. There were 48 nipples included in the >1 year group. Of the 48 nipples, 4 (8.3%) noted normal sensation and 30 (62.5%) noted minor diminished or diminished sensation, indicating nerve reinnervation. For the remaining 14 nipples, 14 (29%) noted loss of protective sensation or deep sensation only. CONCLUSION: Sensory outcomes in NAC grafts used for reconstruction in patients undergoing double incision mastectomy remain poor. Sensation restoration beyond that expected from full thickness skin grafts can be achieved in the majority of patients with nerve allograft via direct neurotization.

Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy.

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.

Degree of satisfaction of women treated with reconstruction and dermopigmentation of the nipple-areola complex after breast reconstruction.

OBJECTIVE: To evaluate the degree of satisfaction of women treated with dermopigmentation and reconstruction of the Areola-Nipple Complex (ANC) after breast reconstruction, as well as their demographic profile and clinical-evolutionary characteristics. METHODS: Descriptive observational study including 128 women treated with dermopigmentation after oncologic breast reconstruction during 2018. In 2021 they were administered an adapted satisfaction questionnaire, which contains 27 items and categorizes satisfaction from 1-5, in addition other clinical-evolutionary and demographic variables were collected. RESULTS: Mean age was 51 (±9) years, 89.1% had previously undergone PDA reconstruction. Mean satisfaction with dermopigmentation was 4.4 (±0.88) and 3.79 (±1.06) for PDA reconstruction. Complications were rare, but 54.5% (n = 54) of the patients reported that the CAP reconstruction did not offer the expected projection, 91.6% (n = 98) that the color had faded and 51.4% (n = 55) would choose permanent tattooing. It was perceived that, the higher the satisfaction of the CAP, the higher the satisfaction of dermopigmentation, while the older the age and previous chemotherapy treatment the lower the color durability (p value ≤ 0.05). CONCLUSIONS: Patients who underwent reconstructive breast surgery show a high degree of satisfaction with dermopigmentation and surgical reconstruction of the PDA, but reiterate the low projecticity of the dermopigmentation and the surgical reconstruction of the PDA, but reiterate the low degree of satisfaction with the dermopigmentation.

The Impact of Radiation on Nipple Symmetry After Bilateral Nipple-Sparing Mastectomy and Implant-Based Reconstruction: An Objective Analysis.

INTRODUCTION: Radiation therapy can adversely affect outcomes of implant-based breast reconstruction, potentially complicating procedures like nipple-sparing mastectomy (NSM), which is increasingly popular in breast cancer management. This study aims to evaluate the impact of radiation on nipple symmetry in patients undergoing bilateral NSM with implant-based reconstruction. METHODS: We conducted a retrospective analysis using data from an Emory University review board-approved database. This encompassed bilateral NSMs coupled with immediate implant-based reconstructions. The BCCT.core software was employed to objectively measure nipple asymmetry preoperatively and postoperatively. Metrics, such as Breast Retraction Assessment values, upper nipple retraction, lower breast contour, and nipple to midline (NML) discrepancies were quantified. The study included 80 patients with a minimum of 1 year of follow-up; among them, 15 received radiation therapy (RT) while 65 did not. RESULTS: The reconstructions were divided into tissue expander, used in 39 cases (48.8%), and direct-to-implant (DTI), employed in 41 cases (51.2%). The DTIs were further categorized based on the location of the implant: 22 subpectoral and 19 prepectoral. Radiation was applied to 15 breasts, distributed among prepectoral DTI (4), subpectoral DTI (6), and tissue expander (5). Breast Retraction Assessment scores significantly differed between the nonirradiated and irradiated groups (1.49 vs 2.64, P < 0.0004). Nipple to midline differences and Upper Nipple Retraction also significantly varied postradiation, especially when comparing subpectoral and prepectoral implant placements. CONCLUSIONS: Radiation therapy has a detrimental effect on nipple symmetry after bilateral NSM and implant-based reconstruction, with variations seen regardless of the implant's placement or the reconstructive technique utilized. Specifically, subpectoral reconstructions irradiated were prone to lateral nipple displacement, likely related to radiation-induced pectoralis muscle changes, while prepectoral irradiated reconstructions tended to have increased vertical displacement. These insights are crucial for patient education and surgical planning in the context of radiation and breast reconstruction.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization.

ABSTRACT: We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

A novel technique of reverse-sequence endoscopic nipple-sparing mastectomy with direct-to-implant breast reconstruction: medium-term oncological safety outcomes and feasibility of 24-h discharge for breast cancer patients.

BACKGROUND: Due to the short operation time and no need for special instruments, reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) has been rapidly becoming popular in the last three years. However, there has yet to be an evaluation of its oncologic safety or the feasibility of discharging patients within 24 h. MATERIALS AND METHODS: In this single-centre retrospective cohort study, individuals diagnosed with stage 0-III breast cancer between May 2020 and April 2022 who underwent traditional open mastectomy or R-E-NSM with DIBR were included. Follow-up started on the date of surgery and ended in December 2023. Data, including demographics, tumour characteristics, medium-term oncological outcomes, and postoperative complications, were collected and analyzed. Propensity score matching (PSM) was performed to minimize selection bias. RESULTS: This study included 1679 patients [median (IQR) age, 50 [44-57) years]. Of these, 344 patients underwent R-E-NSM with DIBR (RE-R group), and 1335 patients underwent traditional open mastectomy (TOM group). The median [IQR] follow-up time was 30 [24-36] months [29 (23-33) months in the RE-R group and 30([24-36) months in the TOM group]. Regarding before or after PSM, the P value of local recurrence-free survival (LRFS, 0.910 and 0.450), regional recurrence-free survival (RRFS, 0.780 and 0.620), distant metastasis-free survival (DMFS, 0.061 and 0.130), overall survival (OS, 0.260 and 0.620), disease-free survival (DFS, 0.120 and 0.330) were not significantly different between the RE-R group and the TOM group. The 3y-LRFS and 3y-DFS rates were 99.0% and 97.1% for the RE-R group and 99.5% and 95.3% for the TOM group, respectively. The rates of any complications and major complications were not significantly different between the RE-R patients who were discharged within 24 h and the RE-R patients who were not discharged within 24 h ( P =0.290, P =0.665, respectively) or the TOM patients who were discharged within 24 h ( P =0.133, P =0.136, respectively). CONCLUSIONS: R-E-NSM with DIBR is an innovative oncologic surgical procedure that not only improves cosmetic outcomes but also ensures reliable oncologic safety and fewer complications, enabling patients to be safely discharged within 24 h. A long-term prospective multicenter assessment will be supporting.

Is minimal-accessed (endoscopic- or robotic-assisted) nipple-sparing mastectomy contraindicated for large breasts?

BACKGROUND: In the developmental stage of minimal-accessed nipple-sparing mastectomy (MA-NSM), selecting patients with small to medium-sized breasts was common for better cosmetic outcomes and oncological safety. However, the suitability of MA-NSM for large, ptotic breasts remained uncertain. This retrospective study aim to assess MA-NSM outcomes in patients with large breasts. MATERIALS AND METHODS: This retrospective study included patients receiving conventional NSM (C-NSM) and MA-NSM from January 2011 to September 2022, at a single institution. We analyzed perioperative parameters and clinical outcomes based on breast specimen size, classified as small (≤300 g), medium (>300-450 g), large (>450-600 g), and very large (>600 g). RESULTS: A total of 728 patients was enrolled. C-NSM was performed in 51% (371/728) of cases, while MA-NSM was done in 49% (357/728). The overall complication rate of MA-NSM was comparable to C-NSM (p = 0.573), but severe complications (Clavien-Dindo, CD III) was significantly reported more following C-NSM, regardless of breast size. During a median follow-up of 52 months, no significant difference in oncological outcomes was observed. Comparing MA-NSM and C-NSM outcomes in large-very large breasts (>450 g), MA-NSM demonstrated significantly less blood loss (p = 0.036) and lower incidence of severe complications (CD ≥ III) compared to C-NSM (p = 0.002). CONCLUSION: MA-NSM is feasible for large breasts and offers benefits by reducing blood loss and decreasing the incidence of severe complications (CD ≥ III) in this patient group.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results.

INTRODUCTION: Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis. METHODS: A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique. RESULTS: During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003). CONCLUSION: If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

How do women perceive their breast image before and after bilateral therapeutic mammoplasty for early breast cancer?

INTRODUCTION: Bilateral therapeutic mammoplasty (BTM) is commonly performed in the UK during treatment for breast cancer, and the available data show oncological safety. This study aims to compare patient-recorded outcome measures before and after surgery, as well as associated patient factors. METHODS: Between March 2018 and December 2019, patients undergoing BTM for breast cancer completed validated BREAST-Q reduction modules before and 3 months after surgery and a radiotherapy domain at 3 months. Scores were correlated with clinical data. For BREAST-Q scales, a higher score (0-100) represents greater satisfaction or quality of life. RESULTS: 28 patients were included, median age 58 years (IQR 52-64), BMI 32.0 (IQR 27.8-34.0). Of these, 1 had bilateral disease, 2 had multifocal disease, and the remaining had unilateral disease. Most (55%) underwent Wise pattern incision. At 3 months post-operatively, the following outcome scores improved based on the Wilcoxon signed-rank test: satisfaction with breasts (median 44 to 84; p < 0.001), psychosocial wellbeing (57.5 to 83; p < 0.001) and sexual wellbeing (48 to 61; p = 0.029). The improvement in satisfaction with breasts score correlated with the preoperative score (p = 0.011), with a larger increase in patients with a lower baseline score. Physical wellbeing was unchanged overall (median 71 to 72). In all solely post-operative domains (satisfaction with information, outcome, nipples and following radiation), patients reported high levels of satisfaction with outcomes. CONCLUSIONS: Patients reported improved levels of patient-related quality of life measures after therapeutic mammoplasty, including satisfaction with breasts and psychosocial and sexual wellbeing, with high post-operative outcomes in satisfaction with outcome, information and nipples, as well as radiation Q-score.

Clinical Outcomes of Transaxillary Reverse-Sequence Endoscopic Nipple-Sparing Mastectomy and Direct-to-Implant Prepectoral Breast Reconstruction: A Prospective Study of Initial 68 Procedures.

BACKGROUND: Minimal access breast surgery improves cosmetic outcomes over conventional breast surgery but still faces barriers in becoming standard procedure for breast reconstruction. This report introduces a novel technique of transaxillary reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) followed by direct-to-implant prepectoral breast reconstruction (DTI-PBR) and describes its clinical outcomes. METHODS: This prospective study enrolled patients who underwent R-E-NSM and DTI-PBR from March 2021 to December 2021 at a single institution. Perioperative data, surgical complications, oncologic outcomes, and patient- and surgeon-reported cosmetic results were noted. RESULTS: The 60 patients in this study who underwent 68 R-E-NSM and DTI-PBR had a mean age was 40.4 ± 10.3 years. The average durations of uni- and bilateral operations were 156.5 ± 48.3 min and 191.3 ± 36.1 min, respectively. The overall surgical complication rate was 13.3%, including 10.0% of patients with minor complications and 3.3% of patients with major complications. The study had one case (1.7%) of implant loss and one case (1.7%) of skin flap necrosis treated by reoperation. During the median follow-up period of 24 months, one patient (1.7%) who discontinued chemotherapy for myelosuppression experienced liver metastases 5 months postoperatively, and one patient experienced new-onset contralateral ductal carcinoma in situ 24 months postoperatively. The preoperative and 18-month postoperative Breast-Q scores for satisfaction with breasts, psychosocial well-being, sexual well-being, and chest well-being did not differ significantly, and the Scar-Q was 81.2 ± 14.5 points. The good-to-excellent rate in surgeon-reported cosmetic results reached 90%. CONCLUSIONS: Transaxillary R-E-NSM followed by DTI-PBR is a safe and efficient technique with high cosmetic outcomes and reliable medium-term oncologic results.

Elongation of intercostal nerve cutaneous branches for breast and nipple neurotization during breast reconstruction after mastectomy for breast cancer: case-control study.

BACKGROUND: To restore sensation after breast reconstruction, a modified surgical approach was employed by identifying the cut fourth intercostal lateral cutaneous branch, elongating it with intercostal nerve grafts, and coapting it to the innervating nerve of the flap or by using direct neurotization of the spared nipple/skin. METHODS: This was a retrospective case-control study including 56 patients who underwent breast neurotization surgery. Breast operations included immediate reconstruction after nipple-sparing mastectomy (36 patients), skin-sparing mastectomy (8 patients), and delayed reconstruction with nipple preservation (7 patients) or without nipple preservation (5 patients). Patients who underwent breast reconstruction without neurotization were included as the non-neurotization negative control group. The contralateral normal breasts were included as positive controls. RESULTS: The mean(s.d.) monofilament test values were 0.07(0.10) g for the positive control breasts and 179.13(143.31) g for the breasts operated on in the non-neurotization group. Breasts that underwent neurotization had significantly better sensation after surgery, with a mean(s.d.) value of 35.61(92.63) g (P < 0.001). The mean(s.d.) sensory return after neurotization was gradual; 138.17(143.65) g in the first 6 months, 59.55(116.46) g at 7-12 months, 14.54(62.27) g at 13-18 months, and 0.37(0.50) g at 19-24 months after surgery. Two patients had accidental rupture of the pleura, which was repaired uneventfully. One patient underwent re-exploration due to a lack of improvement 1.5 years after neurotization. CONCLUSION: Using the lateral cutaneous branch of the intercostal nerve as the innervating stump and elongating it with intercostal nerve grafts is a suitable technique to restore sensation after mastectomy. This method effectively innervates reconstructed breasts and spares the nipple/skin with minimal morbidity.

Mammoplasty Using Modified Superomedial Pedicle Technique in Severely Macromastia and Ptotic Breasts.

Mammoplasty is a surgery commonly used for macromastia. Many mammoplasty techniques are described, all with their specific pros and cons. However, the concern to avoid serious complications sometimes takes precedence, and the ideal result cannot be. For macromastia and severely ptotic breasts, usually the free nipple-areolar complex (NAC) mammoplasty technique is implemented. The results, however, may only be completely satisfactory regarding cosmetics. Loss of NAC, poor appearance, flabbiness, flattening, and ptosis are among the disadvantages of this technique. This study aimed to present the results of mammoplasty employing the superomedial pedicle technique without interrupting a macromastia central base with a pedicle length of 8 to 18 cm. According to the literature, many plastic surgeons recommend the free NAC rather than the pedicle technique because of the high complication rates in mammoplasties planned for highly ptotic breasts and macromastia. On the other hand, many free NAC techniques and their modifications with pedicle mammoplasty are described. The general conviction is that a standard method, protocol, or technique good for all patients does not exist. Our results are more acceptable both cosmetically and physiologically. Therefore, the superomedial pedicle technique can be modified to achieve ideal results where free NAC mammoplasty is considered for severe macromastia and ptotic patients. This combined method contributes to the viability of NAC by increasing blood supply to breast tissue and providing an ideal breast appearance.

Staged Immediate Nipple Reconstruction With Tube Flap in Immediate Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

BACKGROUND: In the setting of immediate breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, the excessive DIEP flap skin is de-epithelialized and then buried under the mastectomy skin. In this study, by virtue of tube flap technique, we hypothesize that the skin supposed to be abandoned could be transferred to the apex of reconstructed breast mound for nipple reconstruction. METHODS: A total of 60 female patients were recruited between January 2019 and December 2020. All these patients underwent mastectomy including nipple-areola complex and immediate DIEP flap breast reconstruction. A ladder-shaped pedicled flap was raised from the DIEP flap and rolled into a tube. The free end of tube flap was inset into the future nipple position of the reconstructed breast mound 1 week later. After revascularization for 1 month, we divided the previous pedicle and used the tube on the apex of the breast mound to recreate a new nipple. RESULTS: All reconstructed breasts and nipples survived well postoperatively. The average nipple projection was 12.5 ± 2.0 mm immediately after the surgery, which gradually decreased to 9.4 ± 1.5 mm at 1-year follow-up, with the projection loss from the initial measurement as 24.9% ± 1.8%. In total, 51 patients considered the overall impression of breast and nipple reconstruction to be very good or good. CONCLUSIONS: We provided an ideal technique that could improve the maintenance of reconstructed nipple projection and have aesthetically acceptable outcomes, without DIEP flap tissue loss, breast mound distortion, or additional scars.

Expanded Indications for Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients Older Than 60 Years.

INTRODUCTION: Although nipple-sparing mastectomy (NSM) and immediate breast reconstruction (IBR) have long been praised for excellent cosmetic results and the resultant psychosocial benefits, the feasibility and safety of these procedures in patients older than 60 years have yet to be demonstrated in a large population. METHODS: Patients undergoing NSM with or without IBR at the MedStar Georgetown University Hospital between 1998 and 2017 were included. Patient demographics, surgical intervention, and complication and recurrence events were retrieved from electronic medical records. Primary outcomes were recurrence and complication rates by age groups older and younger than 60 years. RESULTS: There were 673 breasts from 397 patients; 58 (8.6%) older than 60 years and 615 (91.4%) younger than 60 years with mean follow-up of 5.43 (0.12) years. The mean age for those older than 60 was 63.9 (3.3) years, whereas that for those younger than 60 was 43.1 (7.9) years (P < 0.001). The older than 60 group had significantly higher prevalence of diabetes, rates of therapeutic (vs prophylactic) and unilateral (vs bilateral) NSM, and mastectomy weight. However, there were no significant differences by age group in complication rates or increased risk of locoregional or distant recurrence with age. CONCLUSIONS: Based on similar complication profiles in both age groups, we demonstrate safety and feasibility of both NSM and IBR in the aging population. Despite increased age and comorbidity status, appropriately selected older women were able to achieve similar outcomes to younger women undergoing NSM with or without IBR.