Local and Distant Recurrence Rates in Skin-Sparing Mastectomies Compared With Non-Skin-Sparing Mastectomies

BACKGROUND: Skin-sparing mastectomies (SSMs) are being used more frequently to treat many cases of breast cancer. This type of surgery maximizes breast skin preservation and facilitates immediate reconstruction, resulting in a superior cosmetic appearance after mastectomy and a more satisfied patient. Although SSMs are becoming more common, there are few data regarding the local and distant recurrence rates. METHODS: A total of 231 patients treated with mastectomies from 1990 to 1998 were studied, including 77 SSM and 154 non-skin-sparing (NSSM) mastectomy patients. RESULTS: The local recurrence rates for SSM and NSSM were 3.90% (3 of 77 patients) and 3.25% (5 of 154 patients), respectively. The local recurrence-free survival at 5 years was 95.3% for SSM patients and 95.2% for NSSM patients (P = .28). The distant recurrence rates of SSM and NSSM were 3.9% (3 of 77 patients) and 3.9% (6 of 154 patients), respectively. The distant recurrence-free actuarial survival at 5 years was 90.2% for SSM patients and 92% for NSSM patients (P = .07). CONCLUSIONS: Mastectomies using the skin-sparing technique do not appear to result in any increase in local or distant recurrence and improve aesthetic results of the immediate reconstruction.     

保留皮肤的乳腺癌根治术后即时乳房及乳头再造

目的　介绍保留皮肤的乳腺癌根治术后即时乳房乳头再造经验。方法　对早期乳腺癌 ,保留乳房皮肤 ,切除乳腺组织和腋窝淋巴结 ,应用下腹部横行腹直肌肌皮瓣即时再造乳房乳头。结果　应用该方法治疗 12例 ,再造乳房形态良好。结论　保留皮肤乳腺癌根治术后即时乳房再造 ,切口隐蔽 ,再造乳房形态效果好 ,对早期乳腺癌患者值得推广应用。     

保留皮肤的乳腺癌改良根治术后即时乳房再造

目的　介绍保留皮肤的乳腺癌改良根治术后即时乳房再造的经验。方法　对早期乳腺癌 ,保留乳房皮肤 ,切除乳腺组织和腋窝淋巴结 ,应用下腹部横行腹直肌肌皮瓣或扩大背阔肌肌皮瓣即时乳房再造。结果　应用该方法治疗 37例 ,再造乳房形态良好。结论　保留皮肤乳腺癌根治术后即时乳房再造 ,切口隐蔽 ,再造乳房形态效果好 ,对早期乳腺癌患者值得推广应用     

Skin-sparing mastectomy in the UK--a review of current practice

BACKGROUND: Skin-sparing mastectomy (was first described in 1991 and has achieved popularity because it facilitates immediate breast reconstruction, preserving the infra-mammary fold and breast envelope. Little is known about the use of skin-sparing mastectomy in the UK. METHODS: All members of the BASO Breast Specialty Group were contacted in June 2001 with a questionnaire to determine the popularity of skin-sparing mastectomy, techniques used, indications, contra-indications and outcomes. RESULTS: Of 300 questionnaires sent, 130 were returned by September 2001. The number of respondents using skin-sparing mastectomy increased from 27 (21%) in 1997 to 95 (73%) in 2001. Of respondents, 35 (23%) avoided skin-sparing mastectomy because of their uncertainty about the benefits (22/35), indications (16/35) or oncological safety (13/35). Where skin-sparing mastectomy was performed, it was combined with immediate breast reconstruction in 90% of cases, using latissimus dorsi (84%), subpectoral (70%) or TRAM flap reconstruction (54%). Skin-sparing mastectomy was performed by breast surgeons alone (62%), or with a plastic surgeon (47%) and the preferred incisions were peri-areolar (68%) and elliptical (26%). Most respondents used skin-sparing mastectomy for prophylaxis, in situ cancer and early invasive disease and avoided skin-sparing mastectomy in patients with skin tethering (62%), where radiotherapy was planned (49%) and in smokers (28%). Complications seen by respondents included skin envelope necrosis (68%), haematoma formation (46%), cosmetic failure (41%) and local recurrence (12%). CONCLUSIONS: Skin-sparing mastectomy is becoming popular in the UK, but experience is limited. The variation in indications and techniques indicate the need to establish evidence-based guidelines for the wider practice of skin-sparing mastectomy in the UK.     

Skin-sparing mastectomy

BACKGROUND: Skin-sparing mastectomy (SSM) is a new technique being used in a variety of clinical settings. This article reviews the published data on SSM to establish its current role in clinical practice. METHODS: A Medline search was carried out using the key words 'skin-sparing mastectomy' to identify English-language articles published between 1990 and 2004 and further material referenced in these publications. RESULTS: SSM is most commonly used for surgical prophylaxis and to treat in situ and early invasive disease in patients who request immediate breast reconstruction. SSM and non-SSM result in similar surgical and oncological outcomes, but skin flap ischaemia is more common after SSM and is associated with a range of risk factors, including smoking. CONCLUSION: SSM has become an established procedure in breast surgery, but there is a lack of prospective data on which to make evidence-based decisions about its use in individual patients.     

Skin-sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma

Background Recent published series demonstrate the safety and effectiveness of skin-sparing mastectomy (SSM) with immediate reconstruction for the treatment of early-stage breast carcinoma. Although several reports have retrospectively evaluated outcomes after breast reconstruction for locally advanced disease (stages IIB and III), no study has specifically considered immediate breast reconstruction after SSM for locally advanced disease. Methods From 1996 to 1998, 67 consecutive patients with breast carcinoma underwent SSM with immediate reconstruction and were prospectively observed. From this group of patients, those with locally advanced disease (stage IIB, n=12; stage III, n=13) were analyzed separately. Tumor characteristics, adjuvant therapy, type of reconstruction, operative time, complications, hospital stay, and incidence of local recurrence and distant metastasis were noted. Results Breast reconstruction consisted of a transverse rectus abdominis myocutaneous flap (n=22) or a latissimus flap plus an implant (n=4). The median operative time was 5.5 hours; the average hospital stay was 5.2 days. Complications required reoperation in three patients (12%): partial skin flap necrosis in two and partial abdominal skin necrosis in one. Surgery on the opposite breast for symmetry was required in one patient (4%). Postoperative adjuvant therapy was not significantly delayed (median interval, 32 days). With a median length of follow-up of 49.2 months (range, 33–64 months), local recurrence was present in only one patient (4%), with successful local salvage treatment, and distant metastasis was present in four patients (16%). Conclusions SSM with immediate reconstruction seems safe and effective and has a low morbidity for patients with advanced stages of breast carcinoma. Local recurrence rates and the incidence of distant metastasis are not increased compared with those of patients who have had modified radical mastectomies without reconstruction.     

Skin-sparing mastectomy and immediate breast reconstruction: incidence of recurrence in patients with invasive breast cancer

The aim of this study was to investigate whether skin-sparing mastectomy (SSM), which is gaining increasing importance and gives well-accepted cosmetic results, provides adequate treatment of the patients' oncologic disease. From 1995 to 2003, 60 patients diagnosed with invasive breast cancer were treated with SSM and complete axillary dissection. All patients underwent immediate breast reconstruction after primary surgery. Patients were treated either with a latissimus dorsi flap or with a transversus rectus abdominis myocutaneous flap. Depending on the intraoperative analysis of frozen sections, 14 patients were treated with preservation of the nipple-areola complex. During a median follow-up of 52 months (4-92 months), four local recurrences (6.6%) occurred. One patient was also found to have contralateral breast carcinoma. Three patients developed distant metastases, and two patients died of their disease a mean of 18 months after primary therapy. Factors associated with local recurrence were tumor size, poor tumor differentiation, and positive node involvement. SSM followed by immediate breast reconstruction is an alternative to modified radical mastectomy in a subset of patients with invasive breast cancer. The risk of local recurrence is low and is associated with such factors as tumor stage, poor tumor differentiation, and node-positive disease. This procedure does not increase the risk of distant metastases, which is comparable to that after other surgical approaches.     

Comparison of aesthetic breast reconstruction after skin-sparing or conventional mastectomy in patients receiving preoperative radiation therapy

Many options exist for the surgical treatment of breast cancer in terms of tumor extirpation and reconstruction. Skin-sparing mastectomy (SSM) with immediate reconstruction offers patients a superior result, but this can be jeopardized by preoperative radiotherapy. We compared the outcomes of reconstruction after SSM or conventional mastectomy (CM) in the previously irradiated breast.We evaluated 41 patients over an 8-year period, who were divided into 3 categories: preoperative radiotherapy prior to SSM (n = 8), CM after preoperative radiation therapy (n = 9), and no chest wall irradiation prior to SSM (n = 20). The first group demonstrated significantly higher frequency of native flap compromise and capsular contracture formation than the other 2 groups.SSM with TRAM or latissimus with implant reconstruction is an esthetically optimal option for the treatment of patients without previous radiotherapy. However, for patients with preoperative chest wall radiation, TRAM flap reconstruction was superior to latissimus flap with implant after SSM.     

乳腺癌保留皮肤乳房切除术的现状和存在的问题

目的综述近年来乳腺癌保留皮肤乳房切除术（SSM）的现状和存在的问题。方法对近年来的相关文献进行分析。结果乳腺癌保留皮肤乳房切除加即时乳房重建术对无皮肤粘连的T1、T2期肿瘤和多中心肿瘤、导管原位癌（DCIS）是安全的手术方式，且不会使辅助治疗延期。将保留乳头乳晕复合体限制在周围型的T1、T2期肿瘤是审慎的态度。皮下乳房切除加即时乳房重建术后是否需要放疗或影响放疗存在争议。结论在有选择的病例中SSM是安全的手术方式，如果需要术后附加放疗最好选择延期乳房重建。     

Impact of skin-sparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery

BACKGROUND: The aim of this study was to compare the outcomes of skin-sparing mastectomy (SSM) with immediate myocutaneous flap reconstruction and partial mastectomy with latissimus dorsi miniflap reconstruction (LDMF) for breast cancer. METHODS: Some 106 disease-free patients (57 SSM, 49 LDMF) who had breast reconstruction between 1991 and 1999 participated in this retrospective review. The mean duration of follow-up was 42 (range 6-102) months. Measured outcomes included surgical complications, functional disability, cosmetic result and psychological morbidity. RESULTS: SSM outcomes were less favourable than LDMF outcomes with regard to postoperative complications (14 versus 8 per cent), further surgical interventions (79 versus 12 per cent), nipple sensory loss (98 versus 2 per cent), restricted activities (73 versus 54 per cent) and cosmetic outcome by panel assessment. Anxiety about residual cancer and ease of breast self-examination were similar in both groups. CONCLUSION: LDMF was associated with fewer adverse surgical and physical sequelae than SSM, without compromising local control or cosmetic outcome. Both operations were associated with low psychological morbidity.     

Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy

Background: Skin-sparing mastectomy, combined with immediate breast reconstruction, has become increasingly popular. However, there are no published long-term data to support its oncologic safety. Our purpose was to evaluate the long-term oncologic risk of skin-sparing mastectomy. Methods: The records of all patients who had undergone treatment of T1 or T2 breast cancer by mastectomy and immediate breast reconstruction, and who were followed for at least 5 years or developed recurrence of disease before that time were reviewed. Local and distant recurrence rates observed in patients treated by skin-sparing mastectomy were compared with those in patients treated by conventional, non-skin-sparing mastectomy. Results: A total of 104 patients were treated with skin-sparing mastectomies. In that group, 6.7% developed local recurrences, 12.5% developed distant metastases, 88.5% remained free of disease, and 7.7% died of their disease. Among the 27 patients who did not have skin-sparing mastectomies, 7.4% had local recurrences, 25.9% had distant metastases, 74.1% remained free of disease, and 18.5% died of disease. These recurrence rates are similar to those reported elsewhere after treatment with conventional mastectomy and without reconstruction. Conclusions: Our findings suggest that skin-sparing mastectomy does not significantly increase the risk of local or systemic disease recurrence in patients with early breast cancer.     

Skin-Sparing Mastectomy with Immediate Breast Reconstruction by a New Modification of Extended Latissimus Dorsi Myocutaneous Flap

Background  The introduction of skin-sparing mastectomy has revolutionized both breast cancer surgery and breast reconstruction. Latissimus dorsi myocutaneous flap is a versatile flap that is gaining renewed popularity with the development of flap modifications and the continued recognition of its reliability and safety. We report our results with a new modification of the extended latissimus dorsi flap after skin-sparing mastectomy for breast cancer. Methods  From January 2002 to January 2006, 140 patients of breast carcinoma had unilateral skin-sparing mastectomy and immediate breast reconstruction. A total of 132 cases of invasive duct carcinoma and eight cases of invasive lobular carcinoma are included. Age ranged from 27 to 53 (median, 40.5) years. Tumor stage was stage I in 22 cases, stage II in 100 cases, and stage III in 18 cases. We performed a new modification to the standard extended latissimus dorsi flap, which allowed us to obtain enough autologous tissue to reconstruct the relatively large breast of the Egyptian women without implant. The postoperative aesthetic results and donor side morbidity, including contour deformity and scaring, were examined. Results  We applied both an objective and subjective aesthetic result monitoring. Aesthetic grading results of breast reconstruction were excellent in 85, good in 42, fair in ten and poor in three cases. Both flap and donor site complications were minor. Patients were followed for a median of 32.4 (range, 12-48) months. During this period of follow-up, no episode of local or distant failure was observed. Conclusions  Skin-sparing mastectomy with immediate breast reconstruction using our new modification of extended latissimus dorsi flap allows single-stage, totally autologous reconstruction with satisfactory aesthetic results and low morbidity.     

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.     

Skin-sparing mastectomy with immediate breast reconstruction: The M. D. Anderson cancer center experience

Background: Skin-sparing mastectomy with immediate reconstruction has become popular with patients because, compared with delayed reconstruction, it improves the cosmetic result, reduces cost and anesthetic risk, and in one stage completes most of the surgical treatment that the patient will ever require for treatment of her breast cancer. In the past, reconstruction was often delayed because of an unwarranted fear of locoregional recurrence or because the patient, having to live for some time with a flat chest wall, would be more appreciative of her reconstruction. This concept is now considered unacceptable, and many women regard this attitude as evidence of a lack of concern for the psychological impact of mastectomy. Method: Provided that the breast skin is not involved with or close to the tumor, we prefer to perform the mastectomy with removal of only the nipple-areolar complex and the tumor biopsy scar. The mastectomy is otherwise the same as a standard modified radical mastectomy with removal of all breast tissue and a level I–II axillary node dissection. Our preference is to use the transverse rectus abdominis myocutaneous flap with a microvascular anastomosis because it provides a better blood supply, reduces abdominal wall muscle sacrifice, and eliminates the bulge from tunneling required by a pedicled flap. Result: Using the skin-sparing technique with immediate reconstruction in 545 patients with early-stage breast cancer, our overall incidence of regional recurrence was 2.6%. Of 95 patients who were followed for >four years, the recurrence rate was 4.2%. Conclusions: Regional recurrence after skin-sparing mastectomy is a function of the biology of the tumor and the stage of the disease and is not affected by the use of immediate reconstruction or skin-preservation mastectomy.     

Skin-sparing mastectomy with immediate breast reconstruction: a 10-year, single surgeon review of 105 consecutive patients

Skin-sparing mastectomy with immediate reconstruction is a newer approach for the treatment of primary carcinoma of the breast which avoids many of the problems seen in patients undergoing linear incision mastectomies. One hundred five patients who underwent 143 skin-sparing mastectomies during the 10-year interval from 1985 to 1995 were reviewed, with average follow-up of 8 years and 4 months (minimum follow-up 4 years and 11 months). Local recurrences occurred in four patients (3.8%), two with stage 0 disease, one with stage I, and one with stage II. The average interval to local recurrence was 6 years and 3 months. Ten patients (8.6%) died of breast cancer, including one of the local recurrence patients. These figures are in general agreement with other published breast cancer data, supporting the oncologic safety of the skin-sparing mastectomy approach.     

Skin-sparing mastectomy

BACKGROUND: Skin-sparing mastectomy represents a new surgical approach that allows a mastectomy while preserving the natural skin envelope of the breast. It facilitates immediate breast reconstruction using an implant or myocutaneous flap, resulting in excellent cosmesis. DATA SOURCES: A PubMed database literature search was performed. CONCLUSIONS: Skin-sparing mastectomy is an oncologically safe technique in selected cases; T1/T2, multicentric tumors, ductal carcinoma in situ, and prophylactic mastectomies are particularly suited to this technique. Further research is required to confirm oncologic safety in T3 tumors. In selected cases, the nipple-areola complex can be preserved. A modification of skin-sparing mastectomy includes the removal of the nipple while preserving the areola. The balance of evidence suggests that skin-sparing mastectomy does not increase the risk of locoregional recurrence. Furthermore, it does not delay adjuvant therapies. Contraindications to skin-sparing mastectomy approaches include inflammatory breast cancer and extensive skin involvement by tumor. Preoperative and postoperative radiotherapy are not a contraindication to skin-sparing mastectomy.     

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.     

Recovery of sensation in immediate breast reconstruction with latissimus dorsi myocutaneous flaps after breast-conservative surgery and skin-sparing mastectomy

In breast reconstruction, sensation in the reconstructed breasts affects the patients' quality of life along with its aesthetic outcome. Fortunately, less invasive procedures such as breast-conservative surgery (BCS) and skin-sparing mastectomy (SSM) have greatly contributed to the improved aesthetic outcome in immediate breast reconstruction. However, there are few reports on the recovery of breast sensation after BCS and SSM. We retrospectively reviewed 104 consecutive patients who underwent immediate breast reconstruction with the latissimus dorsi myocutaneous flap between 2001 and 2006 at our institution. The sensations of pain, temperature, touch, and vibration were examined at the nipple and skin envelope during the follow-up period (range: 12-61 months, mean: 31 months), and a stratified analysis was performed to determine the critical factors affecting the sensation recovery after BCS and SSM. We found that large breast size significantly impaired the recovery of sensation in the nipple and skin envelope after BCS as well as SSM. Older age and high body mass index value were the factors which negatively affected the sensation in the skin envelope after SSM. While all our BCS patients underwent postoperative radiation therapy, it did not negatively affect the recovery of sensation in SSM patients. On the basis of these findings, we could further improve the sensation of the reconstructed breasts after BCS and SSM. Especially after SSM, the use of innervated flaps is recommended in the patients with large breast, increased age, or obesity when the nipple-areola complex is resected.     

Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction

Background: The local recurrence (LR) rate with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has been reported as comparable to the LR rate after conventional mastectomy. However, limited data are available on the prognostic significance and management of LR following SSM. Methods: A prospective database maintained at the University of Texas M. D. Anderson Cancer Center identified 437 SSMs performed for 372 invasive T1/T2 breast cancers between 1986 and 1993. Results: Twenty-three LRs were identified, with a LR rate of 6.2% (23/372). Twenty-two of these (96%) presented as palpable skin-flap masses. The median time to recurrence was 25 months (range, 3 to 98 months). Fourteen patients were treated with a combination of surgery and systemic therapy. Resection of the reconstructed breast was performed in only three patients. Complete local control of the recurrent disease was achieved in 17 patients (74%). Nine patients (39%) developed distant metastatic disease. At a median follow-up of 26 months, 14 of 23 patients (61%) are alive without evidence of disease, and 7 (30%) have died from breast cancer. Conclusions: Because LR rate with SSM is low and likelihood of local control and survival is high, SSM and IBR is an acceptable treatment option for early stage breast cancer.     

Fifteen-year series of skin-sparing mastectomy for stage 0 to 2 breast cancer

BACKGROUND: In 1989, skin-sparing mastectomy started at a number of breast centers in the United States because of an increasing demand for immediate reconstruction and a desire for better cosmetic outcomes. METHODS: To ensure the safety of this new approach, we have reviewed the personal series of a single surgeon using a standardized skin-sparing technique during 1989 to 2004. RESULTS: Skin-sparing mastectomy with immediate reconstruction was performed on 225 patients, and standard mastectomy was performed on 1,022 patients. The age distribution was 8 years younger on average in the reconstructed group. The average follow-up for each group was 49 months. The local recurrence for each group was 1.7% and 1.5% (P > .80). The regional recurrence was 3.8% and 3.9% (P > .80). The average time to local recurrence was similar in each group (33.1 and 32.6 months, P > .80). CONCLUSIONS: A skin-sparing mastectomy does not change the local, regional, or systemic risk to breast cancer patients.