Results of immediate breast reconstruction after skin-sparing mastectomy

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.     

Immediate breast reconstruction with anatomical permanent expandable implants after skin-sparing mastectomy: aesthetic and technical refinements

Use of anatomic permanent expandable implant after skin-sparing mastectomy (SSM) permits a 1-stage immediate breast reconstruction with an optimum breast shape. Preservation of most of the mammary skin after SSM on 1 side and anatomic prosthesis shape on the other makes breast reconstruction easier and enhances the quality of the esthetic results. The authors describe their experience with 40 immediate breast reconstructions after SSM performed over a period of 2 years explaining some technical details. The implant is placed in a submuscular pocket, or preferably, depending upon the condition of the muscles and skin flaps after mastectomy, in a submuscular-subfascial pocket. In this case, the undermining of the pocket is submuscular in its upper part under the major pectoralis muscle and subfascial in the lower part of the breast undermining the adipo-fascial tissues above the anterior serratus muscle. The submuscular dissection is done in continuity with the subfascial dissection to allow the complete closure of the soft tissues over the implant. In this case, the minor consistency of subfascial tissues compared with muscle in the inferior pole of the breast allows the easier and quicker distention of the soft tissue overlying the prosthesis during the inflation phase and ensures a good shape of the breast soon after surgery. Whenever possible, the mastectomy is performed through a periareolar skin incision that is closed with a purse-string suture. Finally, the authors discuss the indications of 2 different-shaped anatomic permanent expandable implants: full-height and short-height prostheses with different shape and fullness of the upper pole of the implant.     

保留皮肤的乳腺癌改良根治术后一期乳房假体再造

目的探讨用硅胶假体植入法修复乳腺癌改良根治术后乳房缺失的疗效。方法2005年6月至11月,10例患者行保留皮肤的乳腺癌改良根治术后,同期于胸大肌后植入硅胶假体再造乳房,并根据冰冻结果决定是否保留乳头乳晕复合体。结果本组病人术后无伤口积液感染,皮肤坏死及异物反应等。10例患者美观效果均满意,其中有4例保留乳头乳晕复合体。所有病人进行术后随访。随访时间为1～6个月。未发现有远处转移和局部复发。无上肢水肿及功能障碍。结论保留皮肤的乳腺癌改良根治术后用硅胶假体行一期乳房再造,具有创伤小、安全、简单、恢复快的特点;再造后乳房美观,效果满意。     

Immediate breast reconstruction with definitive anatomical implants after skin-sparing mastectomy.

One-stage breast reconstruction with definitive implants was the original method of breast reconstruction. It gave a round breast with a fixed shape. Lack of skin after mastectomy was the main concern who led to the development of techniques to provide 'new' breast skin such as autogenous reconstruction and tissue expanders. This made the use of definitive implants almost obsolete. Since skin-sparing mastectomy (SSM) basically removes the mammary gland and the nipple-areolar complex preserving almost all mammary skin, it makes the use of definitive implants in immediate breast reconstruction possible again. Moreover, the advent of anatomically shaped implants overcomes the drawback of round shape: the anatomical implant with hyperprojected lower pole and short upper pole matches very well the profile of a real breast. The authors report their experience in 36 immediate breast reconstruction after SSM with short upper pole-hyperprojected silicone gel prostheses carried out between October 2001 and October 2003. In most cases SSM is performed through a circumareolar incision. Axillary dissection is preferably performed through the same incision. The anatomical implant is placed in a submuscular position superiorly and in a subfascial pocket inferiorly. Because of skin redundancy and easy distension of subfascial tissue in the inferior pole of the breast, the implant fills the skin of the inferior mammary pole without needing any skin expansion. Whenever possible, the skin incision is closed with a purse-string suture. The skin will look very wrinkled at the end of the surgery, but it will flatten out in a few weeks. The contralateral breast is simultaneously corrected, if needed. Outcome was assessed by evaluation of photographs performed by the authors, by the patients themselves and by a blinded group of surgeons who evaluated breast volume and shape, breast symmetry, and overall outcome. More than 90% of each of these parameters was scored as good or excellent. Complication rates was low with a 8.3% rate. The use of definitive implants in immediate breast reconstruction after SSM is a one-stage breast reconstruction with low morbidity and very good results, and it is associated with high level of patient and surgeon satisfaction.     

67例保留皮肤的乳腺癌根治术单囊假体植入即刻再造

目的回顾性总结保留皮肤的乳腺癌根治术后即时应用单囊假体植入再造乳房的经验。探讨手术适应证、方法和效果的改进。方法67例患者先行保留皮肤的乳腺癌根治术,然后同时植入单囊假体再造乳房。结果所有患者随访48个月。2例出现轻微并发症即1例皮瓣局部坏死,1例保留乳头乳晕部分坏死。优良率达97%。结论乳腺癌根治术后单囊假体植入适用于健侧乳房较小的患者,手术操作简单,假体植入近期效果好,可基本满足患者日常需要。     

One-stage immediate breast reconstruction with implant following skin-sparing mastectomy in Asian patients

The Asian breast reconstruction patient is usually of lower mean age, lower body mass index (BMI), and has relatively small breasts. This study aimed to investigate the outcome of 1-stage immediate breast reconstruction using saline-filled implants in the Asian patients.Between April 2002 and July 2005, 30 patients underwent skin-sparing mastectomy and 1-stage immediate breast reconstruction with a saline-filled implant. Mean age was 42.9 years, with a mean BMI of 21.9 and a mean implant volume of 283 mL.The overall success rate was 96.6%, with 1 case of implant exposure secondary to chest skin necrosis. At mean follow-up of 21.5 months (range 6 to 40 months), 1 patient developed local recurrence (3.33%).Perfusion of the chest skin flap is reliable enough to allow 1-stage breast reconstruction with small saline-filled breast implants. We present this as an additional option for immediate breast reconstruction in thin women with small breasts.     

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy is becoming an increasingly performed procedure in patients with ductal carcinoma in situ, early invasive breast cancer, and prophylactic mastectomy. Through a periareolar approach, it is possible to remove the breast parenchyma along with the nipple areola complex, preserving almost all the original skin envelope and the inframmamary fold. The TRAM flap is used to recreate the volume and shape of the original breast. This technique has higher quality and easier reconstruction. The major disadvantages, extensive scar and donor site skin color mismatch, are reduced to a minimum level because the former is limited at the natural border of the nipple areola and the latter can be effectively concealed with proper nipple reconstruction. Thirty-one patients with a mean age of 39 years (range, 26-50 years) who had undergone unilateral or bilateral mastectomy for early breast cancer and immediate breast reconstruction with the pedicled TRAM flap were retrospectively reviewed. Requirements for the skin-sparing mastectomy technique include suitability of donor site tissue for autologous tissue, early breast cancer or ductal carcinoma in situ, and adequate size and shape matching of the contralateral breast. There was no observed local recur- rence during the follow-up period (mean, 20 months; range, 11-30 months). Complications at the recipient site include mastectomy skin flap partial necrosis in 2 patients and cellulitis of the transferred flap in 1 patient. No total or partial flap necrosis was observed. One patient developed abdominal bulging 1 month after the operation, during the administration of chemotherapy. All reconstruction was considered very satisfactory from an aesthetic perspective by the surgeon and the patient. The nicer aesthetic result with oncological safety is achieved with immediate breast reconstruction with the TRAM flap after skin-sparing mastectomy. The risk of local recurrence is not higher compared with more radical surgical techniques.     

Risk of residual breast tissue after skin-sparing mastectomy

Abstract: Skin‐sparing mastectomy (SSM) is an accepted surgical option for breast cancer treatment. SSM allows for preservation of the skin envelope and improved cosmesis. Despite initial concerns, large series have not revealed higher recurrence rates. There is, however, a paucity of data regarding the rates of residual breast tissue (RBT) left behind after SSM, what factors influence this, and the oncologic implications of RBT. Retrospective review identified 288 total mastectomies. Patients who had undergone SSM with excision of additional skin for reconstructive purposes, either at the initial oncologic surgery or at subsequent revision, were included in the final study group. Pathologic analysis was performed to evaluate excised skin. Data regarding demographics, tumor type, and treatment were collected. Comparison between patients who had pathologically confirmed RBT in the excised skin and those who did not was performed. Of 288 total mastectomies, 92 were SSM’s, and 66 had skin specimens removed for nononcologic reasons, of these, 4 (6%) had RBT. Age at diagnosis (p = 0.806), BMI (p = 0.531), tumor size (p = 0.922), and estrogen receptor status (p > 0.999) did not contribute to increased RBT risk. At median follow‐up of 33.5 months, there have been no recurrences. In addition, cost analysis reveals it is likely not cost‐effective to perform pathologic evaluation of these specimens. SSM, performed at an academic medical center by fellowship‐trained surgeons, has a very low rate of RBT, and does not compromise oncologic outcomes. Routine pathologic assessment of these skin specimens, removed for nononcologic reasons, may not be required.     

Ultra-conservative skin-sparing 'keyhole' mastectomy and immediate breast and areola reconstruction

The popularity of skin-sparing mastectomy (SSM) which preserves the breast skin envelope is increasing, but the risks and benefits of this approach are only beginning to emerge. A technique involving ultra-conservative SSM and immediate breast reconstruction (IBR) has been evaluated to establish the surgical and oncological sequelae of skin conservation. Between 1994-1998, 67 consecutive patients underwent 71 SSM and expander-assisted immediate latissimus dorsi (LD) breast reconstructions (follow up, 24.1 months; range, 2-52 months). Breast resection, axillary dissection and reconstruction were performed through a 5-6 cm circular peri-areolar 'keyhole' incision. Patients were discharged 6.5 days (range, 5-15 days) after the 3.9 h (range, 3.0-5.5 h) procedure, and expansion was completed by 4.0 months (range, 0-10 months). Local recurrence occurred in 3% of breasts at risk, skin envelope necrosis occurred in 10%, and contralateral surgery was required to achieve symmetry in 14%. SSM and IBR is an oncologically safe, minimal-scar procedure which can be performed by surgeons trained in 'oncoplastic' techniques. It results in low rates of local recurrence and complication, and reduces the need for contralateral surgery.     

乳腺癌保留皮肤全乳切除一期乳房重建129例临床分析

目的 探讨乳腺癌保留皮肤全乳切除(SSM)联合一期乳房重建(IBR)的安全性、适应证、美容效果及其对辅助治疗的影响.方法 对1999年10月至2007年5月共129例接受SSM+IBR手术的乳腺癌患者进行回顾性分析.采用背阔肌或背阔肌联合假体、带蒂横行腹直肌肌皮瓣等方法行乳房重建.结果 平均住院18.6 d,术后首次化疗开始时间平均为术后第5.2天.假体包囊挛缩11例(11/63,17.5%),背部供区血清肿24例(24/99,24.2%),腹直肌肌皮瓣或腹壁下动脉穿支皮瓣部分坏死或硬结9例(9/28,32.1%).未接受放疗患者对重建乳房外观的可接受度为89.7%,高于接受放疗患者的68.2%(P<0.01).随访2-73个月,中位随访11个月.局部复发5例,远处转移7例.结论 SSM+IBR对于0～Ⅱa期乳腺癌患者是安全的,能同时满足肿瘤治疗及形体美容的要求.放疗对于重建乳房的外观有一定的负面影响,对于需要术后放疗的患者,可以考虑延期或者延期-即时乳房重建.     

Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer

OBJECTIVE: To examine the incidence of local recurrence (LR) and factors associated with it in a population of patients who underwent skin-sparing mastectomy (SSM) and immediate reconstruction for invasive carcinoma. SUMMARY BACKGROUND DATA: The efficacy of SSM has been challenged by concerns about increased risks of LR. METHODS: A consecutive series of 173 patients (176 cancers) with invasive carcinoma underwent SSM and immediate breast reconstruction (June 1986 to December 1997). Data were analyzed by the Kaplan-Meier method, the log-rank statistic test, and the Cox proportional hazards model. RESULTS: Mean patient age was 47 +/- 9 years (27% were 40 or younger). The AJCC stages were 1 = 43%, 2 = 52%, and 3 = 5%. Thirty percent of tumors were poorly differentiated. With a median follow-up of 73 months, the LR rate was 4.5%. The mean local relapse-free interval was 26 months. Seventy-five percent of patients who presented with LR developed distant metastases and died of disease within a mean of 21 months. On univariate analysis, factors associated with higher LR rate were tumor stage 2 or 3, tumor size larger than 2 cm, node-positive disease, and poor tumor differentiation. Actuarial 1-, 3-, and 5-year overall survival rates were 98%, 94%, and 88%, respectively. On multivariate analysis, factors associated with decreased survival were advanced stage, presence of LR, and absence of hormone therapy. LR was a highly significant predictor of tumor-related death. CONCLUSIONS: There is a low incidence of LR after SSM, and it is associated with advanced disease at presentation. LR is an independent risk factor for tumor-related death.     

Scientific Presentation Award. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction

BACKGROUND: Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them. METHODS: We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database. RESULTS: Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant differences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy (P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ (P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur (P = .0006). CONCLUSIONS: Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.