Breast reconstruction using a staged nipple-sparing mastectomy following mastopexy or reduction.

BACKGROUND: To address those patients who do not meet anatomical criteria for nipple-sparing mastectomy, the authors use a staged approach: (1) mastopexy or breast reduction, (2) nipple-sparing mastectomy through the mastopexy incisions after a minimum of 3 to 4 weeks, and (3) the final reconstruction. METHODS: Fifteen patients underwent nipple-sparing mastectomy at Georgetown University Hospital between 2007 and 2010 after planned or unrelated mastopexy or reduction. An institutional review board-approved retrospective chart review recorded demographic information and outcomes such as skin necrosis and device failure. RESULTS: Fifteen patients (24 breasts) underwent nipple-sparing mastectomy after mastopexy or reduction with an average follow-up of 13 months. The staged procedure was planned in 10 patients [19 breasts (79 percent)] and unplanned, or coincidental, in five [five breasts (21 percent)]. The mastectomy was prophylactic in 17 breasts (71 percent) and therapeutic in seven (29 percent). Four of the 24 operated breasts (17 percent) experienced a complication. Two patients [two breasts (8 percent)] developed skin flap necrosis. Two patients [three breasts (13 percent)] developed minimal partial nipple-areola complex necrosis. One patient [one breast (4 percent)] had an expander explanted for infection related to skin flap necrosis. Fourteen patients [23 breasts (96 percent)] successfully recovered following nipple-sparing mastectomy and prior mastopexy or reduction without residual effects of nipple-areola complex or skin flap necrosis. CONCLUSIONS: The authors are comfortable offering the staged approach to nipple-sparing mastectomy to patients with moderately large or ptotic breasts. It may not be suitable for the very large or ptotic breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nipple-sparing mastectomy for prophylactic and therapeutic indications.

BACKGROUND: Nipple-sparing mastectomy remains controversial and its adoption has been slow because of oncologic and surgical concerns. METHODS: A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactic indications for which records were available. RESULTS: Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women. Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients. A subareolar biopsy specimen was taken in 39 of 49 breasts (80 percent); four (10 percent) revealed ductal carcinoma in situ, and the nipple or nipple-areola complex was later removed. Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised. With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex. The remaining 113 mastectomies (70 percent) were performed prophylactically on 80 patients. The subareolar tissue was biopsied in 80 breasts (71 percent). One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer. Two nipple-areola complexes (1.8 percent) were ischemic and excised. With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex. CONCLUSIONS: Nipple-sparing mastectomy can be safe in properly selected patients. A subareolar biopsy can effectively identify nipple-areola complexes that may harbor cancerous cells. Ischemic complications resulting in nipple loss can be minimized, and long-term follow-up suggests that this technique deserves further investigation in properly selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Chronic postoperative breast pain: danger zones for nerve injuries.

BACKGROUND: Postoperative breast pain is a frequent complaint, reported by 50 percent of women following a breast procedure. Breast pain interferes with sexual activity, as reported by 48 percent of patients, exercise (36 percent), social activity (13 percent), and employment (6 percent). METHODS: To define neurogenic causes of chronic postoperative breast pain, the authors performed a retrospective review of consecutive patients from a single surgeon and performed 10 anatomical bilateral dissections. The authors evaluated the most commonly injured nerves, based on zone of injury, injury type, and precedent breast procedure. Dissections referenced the zone of injury with the specific procedure and designated the individual nerves at risk. RESULTS: The authors identified 57 patients with chronic breast pain from breast reconstruction (n = 38), reduction (n = 2), mastopexy (n = 2), augmentation (n = 4) and irradiation (n = 11). On the basis of anatomic innervation, the authors designated five zones of nerve injury: superior, medial, inferior, lateral, and central/nipple-areola complex. The lateral zone was most commonly injured (79 percent), followed by inferior (10.5 percent), medial (5 percent), central (3.5 percent), and superior (2 percent) zones. Forty-two patients suffered intercostal nerve neuromas from mechanical nerve trauma/entrapment, with pain at the surgical scar or nearby tissue dissection. Four patients with traction-stretch neuropathy had pain from blunt augmentation pocket dissection. Eleven patients with irradiation-induced neuropathy had diffuse, nonlocalized nerve pain. CONCLUSIONS: By shifting the approach to chronic breast pain from "global chronic breast pain" to defined danger zones of nerve injury, the practitioner can identify the type of nerve injury and associate the most common nerve injury to a given breast procedure. This approach should assist in diagnosis and treatment, and ultimately improve patient morbidity.

Posttraumatic maxillomandibular reconstruction: a treatment algorithm for the partially edentulous patient.

Maxillofacial injuries in the partially edentulous patient present unique challenges that are best treated in conjunction with appropriate dental specialists. Many surgeons who treat complex maxillofacial injuries are not involved in the process of reconstruction of the occlusion and alveolus; however, dental rehabilitation is an important and often overlooked component of treatment of the partially edentulous patients. Working with dental specialists and understanding the role they play in perioperative planning, the plastic surgeon is in a position to optimize reconstruction and rehabilitation of these injuries. The appropriate dental specialists working with the plastic surgeon can provide the surgeon with the necessary orthodontic, prosthodontic, and radiologic expertise that is required to successfully treat these patients. In this article, the authors present their management algorithm for maxillomandibular rehabilitation in the partially edentulous patient and discuss the role of the appropriate dental specialists for obtaining optimal aesthetic and functional outcomes.

Utility of PET/neck MRI digital fusion images in the management of recurrent or persistent thyroid cancer.

BACKGROUND: Approximately 30% of thyroid cancer patients present with reappearing disease within 40 years of initial diagnosis. Hence, sensitive postsurgical monitoring techniques are imperative to successful long-term care. The objective of this study was to assess the added clinical utility of a combined positron emission tomography/magnetic resonance imaging (PET/MRI) of the neck in conjunction with standard imaging in the detection of recurrent thyroid carcinoma. We define standard imaging as a neck sonogram, 131I scan, computed tomography, and MRI. METHODS: This study included 34 patients treated for thyroid cancer at Washington Hospital Center. All patients had previously undergone near-total or total thyroidectomy, standard follow-up imaging studies, and laboratory studies. Twenty-nine of thirty-four patients had received at least one 131I treatment prior to the study. Each patient received a PET and MRI scan, and these images were subsequently digitally fused. RESULTS: Individually and blinded, four endocrinologists retrospectively reviewed all information in patient charts prior to PET and PET/MRI coregistration. A clinical assessment and treatment plan were devised with these data. Following the initial assessment, the endocrinologists were provided results from the PET and PET/MRI fusion studies and asked to make a revised assessment and treatment plan. For each patient, the physicians categorized PET/MRI fusion results as providing new information that altered the initial treatment plan, providing new information that confirmed the initial treatment plan, or providing no additional information. On average, PET/MRI coregistration provided additional information that altered the treatment plan in 46% of the cases, provided additional information that confirmed the treatment plan in 36% of cases, and did not provide any additional information in 18% of cases. CONCLUSION: The combination of structural and functional data that PET/neck MRI fusion offers provided further information in an overwhelming majority of thyroid cancer patients in this study. Thus PET/MRI can be a useful tool in surgical planning, radioactive iodine therapy decisions, and determining the level of follow-up necessary for each patient.