Pregnancy-Associated Breast Changes after Nipple-Sparing Mastectomy.

BACKGROUND: Women of reproductive age are chronically underrepresented in breast cancer studies. Recent studies suggest that almost 40% of patients diagnosed with breast cancer who are of reproductive age want to have children after completing treatment. In this study, the authors evaluated patients of reproductive age who had undergone nipple-sparing mastectomy (NSM) and implant-based reconstruction. The authors compared those who became pregnant with those who did not with respect to clinical and radiologic changes that are reported at follow-up. METHODS: Any patient 45 years of age or younger at the time of NSM was determined to be of reproductive age, selected for evaluation, and followed prospectively. The presence or absence of breast examination changes in the setting of pregnancy after NSM was recorded. RESULTS: A total of 36 patients became pregnant after NSM, and 158 patients did not become pregnant after NSM. Of those who became pregnant, nearly half reported some clinical change just before or immediately after delivery. These changes included color change and discharge at the residual nipple-areola complex and palpable nodularity elsewhere. For those with palpable changes, an ultrasound was performed and hypoechoic lesions with variable vascularity were identified. For those who went on to excision, lactational hyperplasia was the most common diagnosis. CONCLUSIONS: Ultrasound is an appropriate first-line investigation of breast changes, which can include hyperplasia of remaining ductal and glandular tissue. Patients who became pregnant after NSM commonly had clinical breast examination changes, but the majority of these changes were found to be benign on further evaluation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Tumor-to-Nipple Distance as a Predictor of Nipple Involvement: Expanding the Inclusion Criteria for Nipple-Sparing Mastectomy.

BACKGROUND: A tumor-to-nipple distance of greater than 2 cm has traditionally been considered a criterion for nipple-sparing mastectomy. This study evaluates whether magnetic resonance imaging and sonographic measurements of tumor-to-nipple distance accurately reflect the risk of nipple involvement by disease. METHODS: All nipple-sparing mastectomy cases with implant-based reconstruction performed by the senior author between July 2006 and December 2014 were retrospectively reviewed. Therapeutic cases with preoperative magnetic resonance imaging or sonography were included. RESULTS: One hundred ninety-five cases were included. Preoperative imaging consisted of sonography (n = 169), magnetic resonance imaging (n = 152), or both (n = 126). With sonography, nipple involvement did not differ between nipple-sparing mastectomy candidates and noncandidates using a tumor-to-nipple distance cutoff of 2 cm (10.7 percent versus 10.6 percent; p = 0.988) or 1 cm (9.3 percent versus 15.0 percent; p = 0.307). With magnetic resonance imaging, nipple involvement did not differ between candidates and noncandidates using a cutoff of 2 cm (11.6 percent versus 12.5 percent; p = 0.881) or 1 cm (11.4 percent versus 13.8 percent; p = 0.718). When sonography and magnetic resonance imaging findings were both available and concordant, nipple involvement still did not differ between candidates and noncandidates using a cutoff of 2 cm (8.8 percent versus 11.8 percent; p = 0.711) or 1 cm (7.6 percent versus 14.3 percent; p = 0.535). CONCLUSION: A tumor-to-nipple distance as small as 1 cm, as measured by sonography or magnetic resonance imaging, should not be considered a contraindication to nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Nipple Resection and Reconstruction After Attempted Nipple-Sparing Mastectomy.

BACKGROUND: Occult nipple malignancy is detected in 0% to 58% of attempted nipple-sparing mastectomies (NSM), prompting excision of the nipple. We report our experience with nipple resection following attempted NSM and our outcomes with subsequent nipple reconstruction. METHODS: An institutional review board-approved retrospective review was performed of attempted NSM cases with immediate implant-based reconstruction from July 2006 to April 2015. Patients who underwent nipple excision were identified. Indications for excision, pathology reports, and reconstructive outcomes were reviewed. RESULTS: Five hundred sixty-eight NSMs were performed in 330 patients. Thirty-four (6%) cases underwent nipple excision, 53% for positive frozen sections, 29% for positive permanent sections, 3% for clinical suspicion, and 15% either at patient request or for symmetry. All of the cases with positive frozen sections had disease on permanent section and 56% had residual disease in the resection specimen. Of the cases with positive permanent sections, frozen sections were negative in 50%, suspicious or atypical in 30%, and not sent in 20% of cases. Thirty percent had residual disease in the resection specimen. Frozen section sensitivity was 64% (or 75% if suspicious and atypical findings are included). There were no false-positive results on frozen section. Sixty-eight percent of cases have undergone nipple reconstruction by CV flap (57%), skate flap (39%), or nipple-sharing technique (4%). The aesthetic result after reconstruction was excellent in 83% of cases. CONCLUSIONS: Our findings support the benefit of intraoperative subareolar frozen section for detection of occult disease. When nipple excision is required, patients can still achieve an excellent aesthetic result with reconstruction.

Transition from Round to Shaped Implants in Immediate Breast Reconstruction: Our Preferred Approach and Clinical Outcomes.

BACKGROUND: Smooth, round, silicone implants predominate device-based breast reconstruction in the USA; despite their prevalence, complications can include bottoming out, superior contour deformity, rippling, and/or lateral malposition. This complication profile increases the need for revision surgery and subsequent patient dissatisfaction. With the resurgence of shaped, textured, silicone implants in the USA, we report the senior author's success with these devices and outline a strategy to optimize outcomes in breast reconstruction surgery. METHODS: A retrospective chart review was conducted on a prospectively collected IRB-approved database of nipple-sparing mastectomies (NSMs) with immediate breast reconstruction with smooth, round, silicone implants (Group A) in 2011 in comparison to textured, shaped, silicone implants (Group B) in 2012. Changes in operative technique were highlighted and extrapolated. Outcomes were reviewed. RESULTS: In Group A, 128 NSMs were performed in 76 patients. In Group B, 109 NSMs were performed in 59 patients. Thirteen percent of patients in Group A had direct to implant reconstruction as compared with 21% in Group B. Patients with textured, shaped implants were more likely to have acellular dermal matrix (61 vs 34%, p < 0.0001) than those with smooth, round implants. Patients who had smooth, round implants were more likely to have postoperative nipple malposition (18 vs 0%, p < 0.0001,) and rippling (29 vs 0%, p < 0.0001.) Patients with textured, shaped implants had fewer operative revision reconstructions as compared with those with smooth, round implants (36.71 vs 12.8%, p < 0.0001) Based on these results, our technique has evolved and has eight key technical modifications. CONCLUSION: With a few adaptations in surgical technique, the transition to textured, shaped, silicone devices for breast reconstruction can be seamless with superior breast contour and reduced complications/revision rates. 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 .

Sientra high-strength cohesive shaped technique: roundtable discussion.

UNLABELLED: A panel of board-certified plastic surgeons chaired by Dr Michael Schwartz convened to discuss their respective experiences with the Sientra High-Strength Cohesive (HSC+) shaped silicone gel breast implants (Sientra, Inc., Santa Barbara, CA). The authors have implanted a combined total of over 700 patients. Preoperative planning, surgical techniques, and practice integration tips are among the topics reviewed. The surgeons also present breakthrough cases and describe how the HSC+ textured implants helped them achieve a successful outcome. LEVEL OF EVIDENCE: 5Therapeutic.

Nipple-Sparing Mastectomy via an Inframammary Fold Incision with Implant-Based Reconstruction in Patients with Prior Cosmetic Breast Surgery.

BACKGROUND: Nipple-sparing mastectomy through an inframammary fold incision (NSM-IMF) with implant-based reconstruction (IBR) is a cosmetically preferable approach to breast cancer treatment in appropriate candidates. However, patients who have undergone prior cosmetic breast surgery (CBS) may be at increased risk for postoperative complications secondary to existing surgical scars. OBJECTIVE: To assess whether prior CBS increases the risk of complications following NSM-IMF with IBR. METHODS: A retrospective chart review was conducted for 398 NSM-IMFs with IBR performed between July 2006 and December 2013. CBS cases were identified. Outcomes were reviewed. RESULTS: Of 398 NSM-IMF cases, 41 had prior CBS: 24 augmentations, 12 reductions, three mastopexies, and two augmentation mastopexies. NSM-IMF was performed an average of 8 years following CBS. CBS cases had lower BMIs (P = .040), more breast tissue resected (P = .021), wider breast bases (P = .0002), more single-stage reconstructions (P < .0001), more ADM use (P < .0001), and larger permanent implants (P = .0051) than those without CBS. Postoperatively, CBS cases had higher rates of mastectomy flap ischemia (P = .0392) and hematoma (P = .0335). Among CBS cases, single-stage reconstruction was associated with increased full-thickness flap ischemia (P = .0066). Compared to prior augmentation cases, prior reduction/mastopexy cases had higher rates of capsular contracture (P = .0409) and seroma (P = .0226). CONCLUSIONS: This series is the largest to date to evaluate the success of NSM-IMF with IBR in CBS patients. These women should be cautiously considered for IBR, particularly in the setting of single-stage reconstruction. LEVEL OF EVIDENCE: 4 Therapeutic.

Nipple-sparing mastectomy via an inframammary fold incision for patients with scarring from prior lumpectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability. METHODS: A retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy. RESULTS: The overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7-1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%). CONCLUSIONS: Patients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.

A Comparative Retrospective Analysis of Complications After Oncoplastic Breast Reduction and Breast Reduction for Benign Macromastia: Are These Procedures Equally Safe?

INTRODUCTION: Oncoplastic breast reduction has been shown to be an effective approach to breast conservation surgery in women with macromastia. Clear surgical margins can be achieved while simultaneously improving symptomatic macromastia and enhancing aesthetic outcomes. Little has been written about postoperative complications after this procedure, beyond the risk of locoregional recurrence. This study aimed to compare the complication profile for oncoplastic breast reduction versus reduction for benign macromastia. METHODS: A retrospective review of our experience with oncoplastic breast reduction was performed. This represented a consecutive series of 118 patients undergoing bilateral breast reduction during the 7-year study period from March 2005 to March 2012. There were 64 patients identified who underwent oncoplastic breast reduction. Patients were determined to be a good candidate for breast conservation therapy if it was felt that clear surgical margins could be obtained without mastectomy. Postoperative complications (within 6 weeks of surgery) were compared to a control group of 56 patients undergoing reduction for benign macromastia. The associations between complications and potential risk factors were analyzed using logistic regression. RESULTS: Patients undergoing oncoplastic breast reduction and reduction for benign macromastia had some key differences. In general, macromastia patients were younger (mean age, 42.3 vs 57.5 years; P < 0.001) and had lower body mass index (mean, 26.1 vs 30.6 kg/m2; P < 0.001) compared to those patients having oncoplastic reduction. Within the oncoplastic reduction group, 14 (21.9%) patients had a total of 16 complications; among the benign macromastia group, 9 (16.1%) patients had a total of 10 complications (P = 0.420). On univariate analysis, oncoplastic reduction was not predictive of having a perioperative complication (odds ratio, 1.462; 95% confidence interval, 0.579-3.696; P = 0.422). Body mass index was found to be predictive of having a complication after reduction for either indication (odds ratio, 1.108; 95% confidence interval, 1.018-1.206; P = 0.017). Within the oncoplastic reduction cohort at an average follow-up of 34.6 months (range, 0.3-90.3 months), 5 (7.9%) patients developed locoregional recurrence and 2 patients developed distant metastasis. CONCLUSIONS: Compared with reduction mammoplasty for benign macromastia, a widely accepted procedure, patients undergoing oncoplastic breast reduction were equally likely to have a postoperative complication. Elevated body mass index was shown to be a statistically significant predictor of having a complication after reduction for either indication. Overall complication rates were acceptably low for both procedures.

A novel technique of preserving internal mammary artery perforators in nipple sparing breast reconstruction.

SUMMARY: As nipple-sparing mastectomy with implant-based reconstruction has increased, attention must be paid to the viability of the nipple-areolar complex. This article describes the use of preoperative Doppler ultrasound to identify the internal mammary artery perforators. Preserving the internal mammary artery improves vascular supply to the nipple-areolar complex.

Nipple-areolar complex ischemia after nipple-sparing mastectomy with immediate implant-based reconstruction: risk factors and the success of conservative treatment.

BACKGROUND: Nipple-sparing mastectomy performed via an inframammary fold incision with implant-based reconstruction is an oncologically safe procedure that provides excellent cosmesis. OBJECTIVES: The authors report their experience with conservative treatment of postoperative nipple-areolar complex (NAC) ischemia and an analysis of risk factors for NAC ischemia and conservative treatment failure. METHODS: A retrospective chart review was conducted of 318 nipple-sparing mastectomies performed through inframammary fold incisions with implant-based reconstruction between July 2006 and October 2012. NAC dressings consisted of topical nitroglycerin, external warming for 24 hours, antibacterial petrolatum gauze, and a loose bra for 1 week. Patients were monitored for NAC ischemia as the primary endpoint. NAC ischemia was treated with bacitracin ointment. In cases of full-thickness ischemia, expanders were also partially deflated. RESULTS: Partial- and full-thickness NAC ischemia occurred in 44 (13.8%) and 21 (6.6%) cases, respectively. All partial- and 17 full-thickness cases resolved with conservative treatment. Of these, 7 partial- and 2 full-thickness cases suffered residual depigmentation. Four full-thickness cases required operative debridement. Factors associated with NAC ischemia included increasing age (P = .035), higher body mass index (P = .0009), greater breast volume (P = .0023), and diabetes (P = .0046). Factors associated with conservative treatment failure included increasing age (P < .0001), higher body mass index (P = .014), greater breast volume (P = .020), smoking (P = .0449), acellular dermal matrix use (P < .0001), and single-stage reconstruction (P = .0090). CONCLUSIONS: Postoperative NAC ischemia can be effectively managed conservatively to preserve cosmesis and implant viability. Knowledge of risk factors for NAC ischemia and conservative treatment failure may improve future patient counseling and outcomes.

Immediate implant breast reconstruction with acellular dermal matrix for treatment of a large recurrent malignant phyllodes tumor.

UNLABELLED: Phyllodes tumors (PT) are rare fibroepithelial breast tumors representing less than 1 % of all breast malignancies. These tumors are unpredictable and fast growing with a high local recurrence rate, making this disease challenging to treat. Previous literature focused on surgical resection, and breast reconstruction following a mastectomy in patients with PT is rarely addressed. We report a case of a recurrent malignant PT treated with a nipple-sparing mastectomy followed by immediate single-stage silicone implant breast reconstruction. While PT is a rare breast malignancy that presents challenges with both surgical resection and reconstruction, we demonstrate that nipple-sparing mastectomy with immediate implant breast reconstruction with AlloMax is curative and can offer an appealing cosmetic option. LEVEL OF EVIDENCE V: 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 .

Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction.

BACKGROUND: This article discusses the senior author's (M.T.) experience with nipple-areola complex malposition following nipple-sparing mastectomy, surgical options for treatment, and an analysis of risk factors. METHODS: A retrospective review was conducted on a prospectively collected institutional review board-approved database of nipple-sparing mastectomy cases with immediate device-based reconstruction performed between July of 2006 and October of 2012. Malposition was graded as mild (1 cm), moderate (2 cm), or severe (>3 cm) displacement. RESULTS: Three hundred nineteen nipple-sparing mastectomies were reviewed. Malposition occurred in 44 (13.79 percent). Significant factors were age (p < 0.0001), diabetes mellitus (p = 0.0025), body mass index (p = 0.0093), preoperative sternal notch-to-nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), periareolar mastectomy incision with lateral extension (p < 0.0001), prior radiation (p = 0.0004), prior lumpectomy (p = 0.0125), unilateral nipple-sparing mastectomy (p = 0.0004), and postoperative nipple-areola complex ischemia (p = 0.0174). Smoking status, breast volume resected, implant size, ablative surgeon, acellular dermal matrix, and single-stage reconstruction were not significant. Nineteen patients were satisfied. Eight were not offered surgical correction because of an inadequate skin envelope. Eight had crescent mastopexy, three had implant exchange and pocket revision, four had free nipple grafts, and two had pedicled nipple transposition. There were no incidences of necrosis or malposition after surgical correction. CONCLUSIONS: Nipple-sparing mastectomy followed by immediate device-based reconstruction has a risk of nipple malposition. Various surgical procedures are available to correct nipple malposition based on clinical presentation and are safe in certain populations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Necrotizing soft tissue infection in two patients with multiple myeloma.

BACKGROUND: Necrotizing soft tissue infection (NSTI) remains associated with substantial morbidity and risk of death, especially in immunocompromised patients, such as those with multiple myeloma. Early diagnosis and treatment is crucial, yet particularly complicated in patients with atypical presentations and impaired host defenses. METHODS: A report of two cases of multiple myeloma and NSTI at a single institution. Review of pertinent international literature. RESULTS: Necrotizing soft tissue infections are rare in patients with multiple myeloma. However, when they occur, the presentation may be atypical, and morbidity is high. Anti-tumor chemotherapy must be suspended, worsening an already-guarded prognosis. CONCLUSIONS: A high index of suspicion for NSTI is necessary for immunocompromised patients, such as those with multiple myeloma, in view of the possibility of atypical presentation. Diagnosis may therefore be challenging, and a protracted course is possible because of host immunosuppression.

Horizontal or vertical? an evaluation of patient preferences for reduction mammaplasty scars.

BACKGROUND: In the United States, the inferior pedicle Wise pattern technique of reduction mammaplasty has been well established as a safe and reliable method of reducing breast size while maintaining nipple-areolar vascularity and sensation. Nonetheless, the typical inverted-T scar of the Wise pattern reduction is a consistent source of patient and surgeon dissatisfaction with the operation, which has led to the increased popularity of limited-incision techniques of breast reduction. OBJECTIVE: In this study, it was our goal to evaluate patient preferences for breast reduction scar location. METHODS: A retrospective chart review was undertaken that identified 121 patients who underwent bilateral Wise pattern reduction mammaplasty between July 1999 and June 2004. The patients were asked to rate their satisfaction with the surgery on a 1 to 10 scale and to rate the extent, if any, to which they were bothered by their scars. Those patients who were bothered by their scars were asked to delineate which part of the scar bothered them most--the horizontal component, the vertical component, or the areolar component. A statistical analysis of the results was performed with a standard two-tailed t test and a chi(2) analysis. RESULTS: Of the 121 surveys mailed out, 27 surveys were undeliverable. Fifty-seven of the remaining 94 surveys were returned, for a response rate of 61%. Although 49 of the respondents (86%) were highly satisfied with their surgery, 37 patients (65%) indicated dissatisfaction with their scars. Forty-one patients (72%) responded to the question asking which of the scars was most bothersome. Of these 41 respondents, 10 were bothered by all scars equally. Among the remaining 31 patients, 20 (65%) indicated that the horizontal component bothered them most--a statistically significant proportion (P < .001). Twenty-three of 46 patients (50%) who responded to the questions asking which scar they would erase if they were able to do so indicated that they would erase the vertical scar, which was also statistically significant (P < .001). CONCLUSIONS: Our survey confirms the widespread satisfaction reported by patients who have undergone Wise pattern breast reduction surgery. However, it also demonstrates that a statistically significant number of patients are bothered by their scars. These results underscore the importance of developing techniques that minimize breast reduction scars and suggest that short-scar options would be welcomed by women considering breast reduction surgery.

Effective expansion of alloantigen-specific Foxp3+ CD25+ CD4+ regulatory T cells by dendritic cells during the mixed leukocyte reaction.

Thymic-derived CD25+ CD4+ T regulatory cells (Tregs) suppress immune responses, including transplantation. Here we evaluated the ability of dendritic cells (DCs) to expand alloantigen-specific Tregs in the mixed leukocyte reaction (MLR) that develops from polyclonal populations of T cells. The allogeneic DCs, when supplemented with IL-2 in the cultures, were much more effective than bulk spleen cells in expanding the numbers of Tregs. Likewise, DCs and not spleen cells were effective in sustaining expression of the transcription factor Foxp3 in Tregs, but neither IL-2 nor CD80/86 was required for this effect in the cultures. On a per-cell basis, the DC-expanded, but not unexpanded, Tregs were more potent suppressors of a fresh MLR by CD25- CD4+ T cells. Suppression was 3- to 10-fold more active for MLRs induced by the original alloantigens than for third-party stimulators. When DC-expanded Tregs were introduced into sublethally irradiated hosts, the T cells suppressed graft-versus-host-disease induced by CD25- CD4+ T cells. Again, suppression was more active against the same mouse strain that provided the DCs to expand the Tregs. Therefore, alloantigen-selected Tregs are more effective suppressors of responses to major transplantation antigens, and these Tregs can be expanded from a polyclonal repertoire by DCs.

Hand infections: basic principles and management.

BACKGROUND: An untreated hand infection can lead rapidly to tissue destruction and permanent disability. METHODS: Review of the pertinent English literature. RESULTS: Early diagnosis and timely, effective intervention is crucial to treatment. Anatomically, the hand consists of multiple potential spaces and tissue planes that can become infected with a wide variety of organisms. Thus, a working knowledge of hand anatomy as well as pharmalogical therapies is imperative for successful management. CONCLUSIONS: Knowledge of the basic principles of hand care, relevant anatomy, infectious organisms, and clinical signs of an unusually aggressive infection greatly improves treatment efficacy.

Botox and collagen for glabellar furrows: advantages of combination therapy.

Plastic surgeons frequently administer botulinum toxin A (Botox) or collagen as monotherapy to treat glabellar furrows. This study evaluates the possible advantages of combination therapy. Sixty-five patients with moderate to severe glabellar rhytids were prospectively randomized to receive standard injections of Botox, Zyderm II collagen, or a combination. Improvement in rhytids was assessed over 3 months using patient satisfaction scores and an independent physician evaluation. Baseline wrinkle severity was similar in all 3 groups. By 1 month posttreatment, the combination arm showed significantly greater improvement in furrows (79% compared with only 56% and 50% in the Botox and Zyderm arms, respectively; P < 0.05). At 3 months postinjection, the dual-therapy arm maintained better improvement (57% versus 33% and 27% in the monotherapy arms; P < 0.05). Patient satisfaction further highlighted the superiority of the combination approach. By simultaneously addressing the static and dynamic aspects of glabellar furrows, dual therapy provides optimal treatment of this problem.