Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BACKGROUND: Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle. METHODS: A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis. RESULTS: Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances. CONCLUSION: Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.

Management of gestational gigantomastia with breast reconstruction after mastectomy: case report and literature review.

Gestational gigantomastia (GGM) is a rare complication of pregnancy. The etiology of GGM is yet to be fully established. Treatment methods for GGM include medical therapy and surgery. If medical treatment is unsuccessful, surgery may be required. Currently available surgical interventions are either breast reduction or mastectomy with delayed reconstruction. We report a case of a 25-year-old woman (G1P1) who presented with massive enlargement of both breasts during puerperium. Because of the limited effect of medical therapy, surgical intervention was considered to be the first choice. Bilateral mastectomies with grafting of the nipple-areola complex and immediate bilateral tissue expander implantation were performed. Reconstruction was fully completed 8 months after the initial procedure by replacing tissue expanders with definitive implants. Despite being a benign condition, GGM can turn into a serious problem. GGM can be successfully reconstructed by mastectomy with delayed reconstruction and grafting of the nipple-areola complex.

Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients.

BACKGROUND: The resurgence of prepectoral breast reconstruction has brought strict patient inclusion and exclusion criteria by numerous authors. This article provides an overview of a single surgeon's experience with 201 patients, 313 breasts using immediate, direct-to-implant prepectoral breast reconstruction. The article compares surgical outcomes of different patient cohorts to elucidate risk factors that may predispose patients toward developing complications. METHODS: A retrospective chart review was performed, identifying all patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2018. RESULTS: A total of 201 patients representing 313 breasts were included. A midlateral incision was used in 157 breasts (50.2 percent), followed by a skin-reducing, Wise-pattern in 90 breasts (28.8 percent). Acellular dermal matrix was used in 243 breasts (77.6 percent), free nipple grafts were used in 39 breasts (12.5 percent), and postmastectomy radiation therapy was used in 58 breasts (18.5 percent). Complications requiring operative intervention occurred in 24 breasts (7.7 percent), and minor complications occurred in 23 breasts (7.3 percent). There were no significant differences in complication rates for (1) acellular dermal matrix use versus non-acellular dermal matrix use, (2) Wise-pattern versus other incision, or (3) postmastectomy radiotherapy (p > 0.05). CONCLUSIONS: This represents the largest single-surgeon, direct-to-implant prepectoral cohort in the literature. Surgical complications did not differ with acellular dermal matrix use, incision selection, and the use of postmastectomy radiation therapy. There may be an association between acellular dermal matrix use and major complications and radiotherapy with minor complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Acellular Biologic Nipple-Areolar Complex Graft: In Vivo Murine and Nonhuman Primate Host Response Evaluation.

There are more than 3 million breast cancer survivors living in the United States of which a significant number have undergone mastectomy followed by breast and nipple-areolar complex (NAC) reconstruction. Current strategies for NAC reconstruction are dependent on nonliving or nonpermanent techniques, including tattooing, nipple prosthetics, or surgical nipple-like structures. Described herein is a tissue engineering approach demonstrating the feasibility of an allogeneic acellular graft for nipple reconstruction. Nonhuman primate (NHP)-derived NAC tissues were decellularized and their extracellular matrix components analyzed by both proteomic and histological analyses. Decellularized NHP nipple tissue showed the removal of intact cells and greatly diminished profiles for intracellular proteins, as compared with intact NHP nipple tissue. We further evaluated the biocompatibility of decellularized grafts and their potential to support host-mediated neovascularization against commercially available acellular dermal grafts by performing in vivo studies in a murine model. A follow-up NHP pilot study evaluated the host-mediated neovascularization and re-epithelialization of onlay engrafted decellularized NAC grafts. The murine model revealed greater neovascularization in the decellularized NAC than in the commercially available control grafts, with no observed biocompatibility issues. The in vivo NHP model confirmed that the decellularized NAC grafts encourage neovascularization as well as re-epithelialization. These results support the concept that a biologically derived acellular nipple graft is a feasible approach for nipple reconstruction, supporting neovascularization in the absence of adverse systemic responses. Impact statement Currently, women in the United States most often undergo a mastectomy, followed by reconstruction, after being diagnosed with breast cancer. These breast cancer survivors are often left with nipple-areolar complex (NAC) reconstructions that are subsatisfactory, nonliving, and/or nonpermanent. Utilizing an acellular biologically derived whole NAC graft would allow these patients a living and permanent tissue engineering solution to nipple reconstruction.

Top Surgery in Transgender Men: How Far Can You Push the Envelope?

BACKGROUND: The authors present their grading scale and the outcomes of the largest cohort of top surgery published to date. Application of this grading system can help determine which patients will benefit from a subcutaneous mastectomy with free nipple graft versus a circumareolar technique, with the primary endpoint being need for aesthetic revisions. METHODS: The authors reviewed their database of transgender males who underwent bilateral mastectomy between 2006 and 2015. Data collected included age, body mass index, American Society of Anesthesiologists class, smoking, diabetes, testosterone use, months of social transition, technique used, postoperative complications, and need for revision. Two techniques were used, circumareolar incision and free nipple graft technique. RESULTS: Between 2006 and 2015, 1686 consecutive mastectomies were performed on 843 patients. Of those, 548 patients were excluded because of inadequate follow-up. Of the 295 included, 109 were treated using a circumareolar incision and 186 were treated using a free nipple graft technique. There was no statistically significant difference in complications between the two groups; however, there was a statistically significant difference in the rate of aesthetic revisions in the grade 2B circumareolar incision group (34 percent versus 8.8 percent). CONCLUSIONS: The authors' outcomes are comparable to the literature, and demonstrate that these procedures can safely be performed in an outpatient setting. The authors' grading scale classifies patients and helps the surgeon select a surgical technique. The authors show a statistical difference in rates of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Therapeutic mammoplasty combining partial mastectomy with nipple-areola grafting for patients with early breast cancer: a case series.

PURPOSE: Therapeutic mammoplasty (TM) for breast cancer is a widely practiced oncoplastic technique. Intraductal spread towards the nipple or the location of the cancerous lesion on the central breast may become a contraindication for breast-conserving surgery. We herein report the results of TM in such cases. METHODS: Six patients underwent TM that combined partial mastectomy with free nipple-areola (NA) grafting. The nipple was removed together with the cancerous lesions, and the areola was preserved for NA reconstruction. The tumors were located in the lower quadrant (n = 1), the central area (n = 1), the upper-outer area (n = 2), and the upper-inner area (n = 2). The types of mammoplasty that were performed included: amputation (n = 1), inverted T mammoplasty (n = 3), and L mammoplasty (n = 2). With the exception of one patient, all patients underwent inverted T mammoplasty on the contralateral breast in order to achieve symmetry. RESULTS: The total surgical and plastic periods ranged from 155 to 235 min (mean 207 min) and 100 to 150 min (mean 121 min), respectively. Oncological safety and excellent cosmetic results were achieved. CONCLUSIONS: TM combining partial mastectomy with NA grafting was successfully performed in patients with early-stage cancer in all quadrant areas.

Objective and subjective evaluation of donor-site morbidity after nipple sharing for nipple areola reconstruction.

Nipple reconstruction is of importance in achieving the best possible aesthetic outcome after breast reconstruction. Nipple sharing is a common technique; this study focused on the potential morbidity at the donor nipple. Between 2008 and 2012, 26 patients underwent nipple sharing at our institution. The donor nipple was examined before and after the procedure (mean follow-up of 21 months). Sensitivity, projection, diameter, and patient satisfaction were evaluated. The sensitivity in the donor nipple decreased, albeit insignificantly, from 1.2 g/mm2 (0.8-1.6) to 1.8 g/mm2 (0.8-4.8) (p=0.054, n=26). The projection due to graft removal decreased from 8.0 mm (6.8-10.0) to 4.5 mm (4.0-5.0) (p=0.001). Of the patients, 88% were "very satisfied" or "somewhat satisfied" with the sensitivity and 89% with the symmetry between the donor and reconstructed nipple. At least 60% of the patients were "very satisfied" with all aesthetic outcome parameters (projection, appearance, naturalness, color, and shape). All patients would agree to undergo this procedure again, if necessary. Nipple sharing was associated with minimal morbidity at the donor nipple. The postoperative projection was adequate. Regardless of whether simultaneous mastopexy was performed, the loss of sensitivity was minimal and presumably imperceptible to the patient. By using no sutures after graft removal and letting the donor nipple heal spontaneously, scarring was minimized and the natural appearance and good sensitivity of the donor nipple were preserved.

[Surgical treatment for gyncomastia].

OBJECTIVE: To introduce different surgical treatment for gyncomastia at different grades. METHODS: 37 cases with gynecomastia were divided into three grades as: grade I with fat as main tissue, grade II with proliferated fibro-gland as main tissue, grade III with big and ptosis breasts and sagging skin. Different surgical methods were chosen according to the different grades of gyncomastia. These include liposuction, subareolar fibroglandular tissue removing, combined technique of the two methods, and breasts resection with free transplantation of nipple-areola complex. RESULTS: All patients were satisfied for the appearance of post-operative flat male chest. Complications, such as scar, numbness of nipple and areola were acceptable for them. CONCLUSIONS: Different surgical methods should be chosen for the gynecomastia at different grades. It can improve both the physical and psychological problems for patients.

[Operative management and techniques of mastectomy in female-to-male transsexuals]. / Operatives Management und Techniken der Mastektomie bei Frau-zu-Mann Transsexuellen.

BACKGROUND: Subcutaneous mastectomy in female to male transsexuals is one first important step in gender adjustment. Beside proper surgical technique, operative management of mastectomy procedures is important to allow for an optimised process of gender transformation including all necessary individual operations. METHODS: 126 female-to-male transsexuals were prospectively included in the observation period, all undergoing a step 1 operation of gender adjustment. The mastectomy procedure is conventionally embedded in an overall approach for gender transformation and was regularly combined with procedures like colpectomy, extension of the urethra as well as hysterectomy and ovariectomy. 4 different methods for mastectomy were introduced at our institution, depending on and adjusted to the breast volume, grade of breast ptosis, the breast size and envelope and skin elasticity. For patient evaluation a standardised survey was conducted using a semiquantitative score (1-4) for grading aesthetic results and nipple sensibility. RESULTS: Between 2006 and 2009 a total of 126 patients underwent a step 1 procedure of gender adjustment, 63 had mastectomy and 29 a revision procedure after external prior mastectomy. In 64/126 (50.8%) mastectomy was performed using a one-third edge cut, 30/126 (23.8%) were operated by a submammarian approach and pedicled nipples technique, in another 22/126 cases (17.5%) mastectomy was performed using circular tightening and 10/126 (7.9%) received freely transplanted nipples. For improving the aesthetic results, additional procedures were performed on 29 patients (46%). The patient survey revealed a high level of satisfaction with the aesthetic result, 42/50 (84%) of the patients rated results as good or very good. CONCLUSIONS: We newly introduced an operative concept of mastectomy being embedded and adjusted in an overall approach for gender adjustment (Munich Modular Operative Kit; MMOK). Using the presented individualised surgical techniques of mastectomy, all procedures were conducted in a very scar-saving manner, however, a higher rate of correction procedures was necessary to individually adjust skin shrinking and thereby optimising the prior aesthetic results. The new Munich Modular Operative Kit allows for gender reassignment including breast corrections usually using 4 operative steps.

Donor-site morbidity and patient satisfaction using a composite nipple graft for unilateral nipple reconstruction in the radiated and nonradiated breast.

BACKGROUND: The number of techniques available for nipple reconstruction underscores the notion that achieving an acceptable result remains a challenge. To better assess the value of a composite nipple graft in unilateral breast reconstruction, a study was performed to evaluate donor-site morbidity and patient satisfaction using a composite nipple graft for unilateral nipple reconstruction following mastectomy and reconstruction in radiated and nonradiated patients. METHODS: A retrospective chart review of all patients who underwent composite nipple reconstruction between October of 1993 and February of 2010 was performed. Medical records were reviewed for outcomes and complications. Each patient was asked to complete a previously validated survey to rate color and projection of both nipples, sensation, and contractility of the donor nipple, and whether she would, in retrospect, have the procedure again. RESULTS: Fifty-nine patients were identified who underwent nipple reconstruction using a composite nipple graft. Thirty-four patients (57.6 percent) responded to the survey. Four surveys were returned due to an invalid address. Average time to breast mound completion was 6 months. Average time to complete nipple reconstruction was 3.6 months after breast mound completion. Ninety-seven percent of the reconstructions were successful. CONCLUSIONS: Composite nipple reconstruction is a useful technique that should be considered in unilateral nipple reconstruction and should be especially considered in patients whose breast has been irradiated, for which flap reconstruction for the nipple can be riskier. Although it is not possible to use in all patients, no other technique provides a nipple reconstruction that can so closely match the contralateral side in color, texture, and overall appearance.

[Two cases of juvenile gigantomastia treated by reduction mammaplasty with nipple-areola complex graft]. / Gigantomastie juvénile: à propos de deux cas traités par la plastie mammaire de réduction avec greffe de la plaque aréolomamelonnaire.

Two cases of juvenile gigantomastia treated by reduction mammaplasty with nipple-areola complex graft. Juvenile gigantomastia or virginal hypertrophy is a volume anomaly of breast of the teenager. It is unsightly. But often, it is pain, impaired spinal posture and the shoulder girdle and the psychological effects that bring the teenager to make an application for aesthetic surgery. We report two cases of juvenile and bilateral gigantomastia in adolescents aged 13 years old and unresolved. They have lost their hope before surgical procedure. In both cases, treatment consisted of a reduction mammaplasty with nipple-areola complex graft according to the technique of Thorek. The total resection was 3500 and 2900 g of breast tissue in one and 4000 g per breast in the other. Satisfaction regarding the shape, size and symmetry of the reconstructed breast was good. Although the effects on breastfeeding remain patent, the psychological impact was favorable in all cases.

Paget disease of a nipple graft following completion of a breast reconstruction with a nipple-sharing technique.

Surgical treatment of breast cancer can have a profound impact on patients both physically and psychologically. Postmastectomy breast reconstruction can significantly decrease the psychologic distress that a breast cancer patient experiences. Whereas breast mound reconstruction was initially thought to be sufficient, surgeons and patients have recognized the importance of nipple-areolar reconstruction. The following is a case report of a patient who developed Paget disease of a left nipple graft after left mastectomy and reconstruction with a TRAM flap and nipple sharing from the right breast. This case report provides a unique 14-year retrospective review of a clinical course and to our knowledge is the first reported case in the English literature of Paget disease developing in a nipple reconstructed from the contralateral nipple using the nipple-sharing technique.

Reconstruction of the nipple-areola complex: an update.

Along with continuing progress in reconstructive surgery of the breast numerous techniques of nipple-areola reconstruction have been developed. With time and experience some methods have been discredited to historical significance only while others have evolved to widely accepted concepts used by surgeons all over the world, which in turn contributed new ideas and modifications. In addition to those favourite techniques others are reserved as second-line alternatives in specific situations. The principle criterion for a pleasing nipple-areola complex is symmetry regarding several parameters: colour, texture, size, and projection. The purpose of this manuscript is to review and discuss the concepts and techniques of nipple-areola reconstruction that have evolved over the past decades. Furthermore, those principles and techniques are pointed out that fulfil best the criteria of an ideal nipple-areola complex with emphasis on different techniques of breast reconstruction and individual conditions of the patient.