Postoperative pain assessment of robotic nipple-sparing mastectomy with immediate prepectoral prosthesis breast reconstruction: a comparison with conventional nipple-sparing mastectomy.

Aims: Nipple-sparing mastectomy (NSM) is a surgical procedure for patients with breast cancer without nipple-areolar complex (NAC) involvement. Robotic NSM (RNSM) with immediate breast reconstruction has been recently introduced; however, reports regarding RNSM are still lacking. Therefore, this study aimed to evaluate the postoperative assessment with a focus on postoperative pain of RNSM with prepectoral immediate prosthesis breast reconstruction (IPBR) compared with conventional NSM (CNSM) in patients with breast cancer without NAC invasion. Methods: This retrospective study included 81 patients who underwent RNSM (n = 40) or CNSM (n = 41) with prepectoral IPBR using direct-to-implant or tissue expander between January 2018 and June 2020. The primary endpoint was to compare postoperative pain intensity based on a numerical rating scale (NRS). The secondary endpoint was to evaluate the postoperative recovery profile, including postoperative nausea/vomiting (PONV) and complications. Results: A statistical difference was observed in the resting NRS scores at 0-6 postoperative hours between the RNSM and CNSM groups (3.2 ± 1.5 versus 4.2 ± 1.6, respectively; Bonferroni corrected P = 0.005), however, no difference was shown at other time periods. Also, no between-group difference was found in the NRS scores for acting pain within 48 postoperative hours and the number of patients requiring additional analgesics. Conclusions: Despite a statistical difference in the resting NRS scores during the early postoperative phase, the absence of any significant difference in the requirement of additional analgesics between the groups suggested that RNSM does not significantly attenuate postoperative pain intensity.

The utility of intraoperative retroareolar margin frozen section assessment and the management of atypical epithelial proliferative lesions at the retroareolar margin in nipple-sparing mastectomies.

OBJECTIVES: Nipple-sparing mastectomy (NSM) has become more frequently utilized due to superior psychological and cosmetic outcomes. The aim of this study was to evaluate the accuracy and utility of intraoperative frozen section evaluation of the retroareolar margin (RAM) in NSM. The management of atypical epithelial proliferative lesions at the RAM was also reviewed and discussed. METHODS: A single institution, retrospective analysis was performed on all therapeutic NSM patients with intraoperative evaluation of the RAM from 2014 to 2018. Patient demographics, tumor characteristics, pathologic assessment of the RAM, surgical management, and clinical follow-up were reviewed. RESULTS: Seventy-four nipple-sparing mastectomies with intraoperative evaluation of RAMs were identified. Concordance was 95% between frozen and permanent section diagnoses with 4 cases representing false negatives and no false positives. There were no instances of nipple-areolar complex (NAC) recurrence in all cases with preserved NACs (mean follow up: 750 days). In the 9 cases where NACs were excised based on intraoperative RAM evaluation, the findings in the excised NACs were negative in 6 and ductal carcinoma in situ in 3 cases. Postoperative measurement of the tumor to nipple distance was the only statistically significant variable associated with a positive RAM by multivariable logistic regression (OR 0.475; 95% CI 0.238-0.946). CONCLUSIONS: Intraoperative RAM evaluation demonstrated high concordance with permanent histology. Negative RAM, including atypical epithelial proliferative lesions, led to NAC preservation without recurrence. Positive RAM alone did not predict NAC involvement, although pagetoid spread of ductal carcinoma in situ along nipple ducts may predict NAC positivity.

The Price of Aesthetics After Nipple-Sparring Mastectomy: A Cost-Minimization Analysis of Skin Banking With Deep Inferior Epigastric Perforator Flap.

BACKGROUND: Skin necrosis after nipple-sparing mastectomy (NSM) and deep inferior epigastric perforator (DIEP) breast reconstruction impacts cosmesis and patient satisfaction. Skin grafting might mitigate these sequelae, but oftentimes creates a color and texture mismatch with native breast skin. In contrast, abdominal skin on the DIEP flap is an excellent match and can be banked. The purposes of this study are to review our experience with skin banking of DIEP flaps and determine the cost-benefit of skin banking compared with other reconstructive options. METHODS: This was a retrospective review study conducted from 2011 to 2014 to examine patients undergoing staged DIEP reconstruction immediately after NSM. Medicare reimbursement costs using Current Procedural Terminology codes, and provider and facilities fees for conventional reconstructions options versus skin banking were obtained with subsequent cost-minimization and sensitivity analyses. RESULTS: The proportion of patients who developed mastectomy skin necrosis was 12.1%, and that of those who had a positive retroareolar biopsy corresponding to an average surface area of 58.3 cm was 3.0%. Average per patient cost of skin banking was $1224, $844 more than split-thickness skin graft (STSG) without Integra, $420 more than STSG with Integra, and $839.01 more than full-thickness skin graft. Sensitivity analysis demonstrates that skin banking was less than managing mastectomy skin loss with STSG and Integra when the incidence of necrosis >10 cm exceeded 25.3%. CONCLUSIONS: Skin banking maximizes aesthetic outcomes after skin loss from either positive margins or skin flap necrosis. Use of this technique should occur especially in select patients at increased risk of mastectomy skin flap/nipple-areola complex (NAC) necrosis and/or suspicion for occult NAC carcinoma. Furthermore, among reconstructive plastic surgeons whose rate of mastectomy flap/NAC necrosis >10 cm exceeds 25.3%, sensitive analysis favors undergoing a staged reconstruction after NSM.

Quantitative assessment and risk factors for nipple-areolar complex malposition after nipple-sparing mastectomy.

PURPOSE: Nipple sparing mastectomy (NSM) for breast cancer preserves the nipple-areola complex (NAC) and has limited the extent of the scar, giving good cosmetic results. However, NAC malposition may occur. The aim of this study is to evaluate NAC malposition after NSM and to determine factors associated with malposition in two-stage reconstruction. METHODS: The subjects were 46 patients who underwent unilateral NSM, without contralateral mastopexy or reduction surgery, in two-stage reconstruction using an expander with implant or flap replacement. Vertical and horizontal NAC malposition and predictors of malposition were evaluated before and more than 1 year after reconstruction surgery. RESULTS: The total amount of saline injected into the expander and aging were significant predictors of increased superior malposition of NAC before and more than 1 year after reconstruction or implant surgery. In contrast, the amount of saline injected into the expander until 2 weeks after expander insertion was a significant predictor of decreased superior NAC malposition. BMI was also a statistically significant predictor of decreased superior NAC malposition, but this result was likely to have been due to the measurement method. Autologous reconstruction was a significant negative predictor of superior malposition at more than 1 year after surgery. Superior NAC malposition resulting from full expansion of the expander improved by a mean vertical angle of 4.5° after autologous reconstruction, but hardly improved after implant use. In autologous reconstruction, NAC tended to move slightly to the lateral side after autologous reconstruction, compared to implant use. CONCLUSIONS: Until 2 weeks after expander insertion, as much saline as possible should be injected to prevent superior NAC malposition. At full expansion, superior malposition of vertical angle > 4.5° may require repositioning surgery.

Prepectoral Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy: An Assessment of Clinical Outcomes and Benefits.

BACKGROUND: Prepectoral breast reconstruction following mastectomy has become a more widely performed technique in recent years because of its numerous benefits for women. These include full pectoralis muscle preservation, reduced loss of strength, reduced pain, and elimination of animation deformity. As with any breast reconstruction technique, widespread adoption is dependent on a low morbidity profile in the setting of postmastectomy radiation therapy, as this adjuvant therapy is routine in breast cancer treatment. The authors assess the clinical outcomes of patients undergoing postmastectomy radiation therapy following prepectoral breast reconstruction, and compare these to outcomes of patients undergoing postmastectomy radiation therapy with submuscular reconstruction. METHODS: A single surgeon's experience with immediate prepectoral breast reconstruction, followed by postmastectomy radiation therapy, from 2015 to 2017 was reviewed. Patient demographics and incidence of complications during the tissue expander stage were assessed. In addition, the morbidity profile of these patients was compared to that of patients undergoing submuscular/dual-plane reconstruction and postmastectomy radiation therapy over the same period. RESULTS: Over 3 years, 175 breasts underwent immediate prepectoral reconstruction, and 236 breasts underwent immediate submuscular/dual-plane reconstruction. Overall rates of adjuvant radiation therapy (postmastectomy radiation therapy) were similar between prepectoral [26 breasts (14.9 percent)] and submuscular [31 breasts (13.1 percent)] (p = 0.6180) reconstruction. There were no significant differences in complication rates between the two reconstructive cohorts, in the setting of postmastectomy radiation therapy, including rates of explantation (15.4 percent versus 19.3 percent; p = 0.695). CONCLUSIONS: Prepectoral breast reconstruction is a safe and effective option in the setting of postmastectomy radiation therapy. The morbidity profile is similar to that encountered with submuscular reconstruction in this setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Intraoperative Assessment of the Relationship Between Nipple Circulation and Incision Site in Nipple-Sparing Mastectomy With Implant Breast Reconstruction Using the SPY Imaging System.

INTRODUCTION: Nipple-sparing mastectomy (NSM) and immediate breast reconstruction with gel implants have grown in popularity because of superior aesthetic outcomes. One risk of this procedure is overexcision of the flap leading to inadequate circulation in the breast envelope. METHODS: We investigated 17 cases of NSM and gel implant breast reconstruction. Patients were divided into an infra-areolar incision group and a supra-areolar incision group. Nipple-areolar complex perfusion was evaluated using the SPY imaging system after NSM and gel implant breast reconstruction. We aimed to discover any relationships between the incision method and nipple-areolar complex (NAC) circulation in NSM and gel implant breast reconstruction. RESULTS: For successful breast surgery, awareness of the blood supply to the breast, especially the NAC, is very important. In our study, with the indocyanine green SPY imaging system, most ingress (arterial inflow) and egress (venous outflow) rates in the infra-areolar incision group were better than those in the supra-areolar incision group (P < 0.005). CONCLUSIONS: We have shown that an infra-areolar incision provides better blood flow following NSM and gel implant breast reconstruction. In our experience, in order to prevent the possible ischemia of NAC, we used the smaller gel implants, which is approximately 10 to 20 mL smaller than the original implant size measured by the sizer, if the egress rate of NAC is lower than 0.2. These findings have implications in the clinical setting as surgeons have a choice to provide a better outcome for patients.

Nipple-sparing mastectomy and immediate reconstruction in ductal carcinoma in situ: a critical assessment with 41 patients.

BACKGROUND: Nipple-sparing mastectomy (NSM) is increasingly popular for the treatment of select breast cancers and prophylactic mastectomy. This study aimed to analyze the authors' 11-year experience with NSM and breast reconstruction in cases of ductal carcinoma in situ (DCIS) with an emphasis on indications, complications, and cancer recurrence rate. METHODS: Between January 2000 and December 2010, 41 NSMs were performed in 41 women for DCIS. The mean age of the women was 49.7±8.7 years (range, 33-66 years). The indications for NSM were tumor size greater than 3 cm (18 cases), multifocal tumor (16 cases), and tumor recurrence (7 cases). In all cases, the tumor was located more than 2 cm from the nipple-areola complex (NAC), as shown by preoperative radiologic imaging. Histologic results, secondary NAC resection, complications, and cancer recurrence rates were recorded. RESULTS: The NAC was lost in seven cases (17%) due to postoperative necrosis. In another 10 patients (25%), the NAC was secondarily removed due to proximity of the tumor to the resection margin. Five patients were lost to follow-up evaluation (12%). The authors report the long-term follow-up data for the remaining 19 patients (46%). In this group, they observed one local recurrence (5.3%) and one case of ovarian cancer. CONCLUSION: Despite the low locoregional recurrence rate for DCIS, NSM remains controversial because of the nipple necrosis observed and the irradical tumor excisions. Given the ethical impossibility of conducting randomized controlled studies to compare NSM with conventional or skin-sparing mastectomy in DCIS, only long-term follow-up evaluations can demonstrate the safety of NSM. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction.

PURPOSE: Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM. METHODS: The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision. RESULTS: Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple-areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions. CONCLUSION: The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.