Nipple centralization for the correction of breast deformity from segmental mastectomy

A breast deformed by lateral tissue deficiency and severe lateral displacement of the nipple, caused by the treatment of an early breast cancer with segmental mastectomy and radiotherapy, was corrected by a modification of techniques used commonly for mastopexy. The nipple and areola were moved medially on a central pedicle to create the illusion that the missing lateral tissues had been restored. Simultaneously, the opposite breast was reduced to improve symmetry. The result was a normalization of breast appearance without the need for distant tissue. It is possible that modifications of this approach could be used to treat similar deformities in other quadrants of the breast as well.     

Nipple sparing mastectomy for a giant phyllodes tumor; a case report

IntroductionOncoplastic surgery has come into the limelight in the surgical treatment of breast cancer. In this report, we will introduce our challenge to apply oncoplastic surgery to a benign neoplasm like phyllodes tumor (PT).Presentation of caseA 45-year-old female visited our hospital complaining of a rapidly growing lump on her left breast. She already had experienced lumpectomy twice on the same breast. Her left breast was occupied by a 14 × 10 cm mass with another small 1.7 × 1.6 cm nodule considered as a daughter lesion. Core needle biopsy suggested that it was a benign PT. We conducted nipple sparing mastectomy (NSM) and immediate reconstruction of the breast by latissimus dorsi muscle flap. During 7-years follow up, she has no recurrence and is satisfied with the reconstructed breast.DiscussionThere are some reports that performed conventional or radical mastectomy with immediate breast or chest wall reconstruction for giant PT. Reports about NSM with breast reconstruction for PT are rare, there are 5 including ours. All the cases accomplished long term recurrent free survival. All except ours were reconstructed by implants. Implant reconstruction is technically easier, but recently, malignant lymphoma after putting breast implant is concerned. Another merit of autologous tissue reconstruction is that they change naturally as age like contralateral breast so that it can achieve better long-term cosmetic result.ConclusionNSM with autologous tissue reconstruction is a good option for PT treatment even though it is not malignant.     

Nipple sparing mastectomy: an innovative skin incision for an alternative approach

Choice of the most appropriate surgical treatment for breast cancer patients can also be a technical issue. Cosmetic results after conservative surgery can be poor in certain instances and, at the same time, total mastectomy can appear as an over-treatment. For some selected patients, the "nipple sparing mastectomy" (NSM) is an alternative surgical treatment and more and more papers on this technique are appearing in the literature. One hundred and two NSMs have been performed in our department between June 2003 and October 2006, initially via periareolar skin incision, now through a skin incision on the lateral aspect of the breast to reduce the necrotic risk for the nipple. The lateral skin incision saves the integrity of skin blood supply, allows for a complete breast gland removal and saves the integrity of the body image of women who show no scars when seen upfront.     

Total skin-sparing mastectomy without preservation of the nipple-areola complex

BACKGROUND: We hypothesized that total skin-sparing mastectomy (TSM) including where the skin overlying the nipple and areola is preserved would be oncologically safe and facilitate improved cosmetic reconstruction. METHODS: A review (May 2003 through January 2005) was completed on all procedures that were performed through an inframammary incision or a previous scar with reconstruction using Botox, AlloDerm, and a subpectoral tissue implant. RESULTS: Thirty-one patients had 50 TSMs. Twelve percent (6/50) of TSMs had the skin of the nipple and areola resected: 4 (14% of tumors) because of tumor involvement and 2 (4%) because of skin necrosis. Fourteen percent of patients had other complications: 4% (2/50) had infection and/or flap necrosis and 10% (5/50) had superficial epidermolysis requiring no intervention, for a total complication rate of 18%. Average cosmetic score was 8.5 (range 4 to 10). No recurrences are evident after mean follow-up of 7.9 +/- 5.4 months. CONCLUSION: Our short-term experience suggests that TSM has an acceptable complication rate, is theoretically oncologically safe, and facilitates an improved cosmetic result.     

Nipple delay prior to nipple-sparing mastectomy: the protective effect on nipple-areola complex ischaemia

BackgroundNipple-sparing mastectomy (NSM) has become increasingly popular over the past decade, offering perceived superior cosmetic outcomes and psychological benefits. The main concern in NSM is that of nipple-areola complex (NAC) ischaemia, occurring in up to 15% of cases. We investigate the utility of nipple delay (ND) in protecting the NAC from ischaemic complications.MethodsA retrospective study of all NSM for a single surgeon from 2010 to 2020 was performed, with those not receiving a prior ND procedure included as a control arm. Variables were recorded, including time to mastectomy from delay, degree of breast ptosis, cup size, mastectomy weight, previous radiotherapy, and presence of ischaemic risk factors. Outcomes recorded were the development of NAC ischaemia, graded from epidermolysis to partial or full-thickness necrosis (FTN).ResultsA total of 62 women for a total of 84 breasts were part of the delay cohort. Ten (12%) breasts in the delay group developed ischaemic complications, with only five breasts developing FTN requiring debridement. Moreover, 33 women for a total of 43 breasts were part of the non-delay cohort. A total of 14 (33%) breasts in the non-delay cohort developed ischaemic complications, with six breasts developing FTN requiring debridement. Delay was protective against ischaemic complications with an OR 0.28 (p=0.007). Mastectomy weight of >600 g and >400 g predicted the development of ischaemic complications in the delay and non-delay cohorts, respectively.ConclusionND was shown to protect against the development of ischaemic complications prior to NSM, with the greatest protective effects shown in those with morphologically large breasts.     

Modified radical mastectomy with preservation of the pectoralis major muscle

A new technique of modified radical mastectomy for early breast cancer was devised with an express purpose of preserving pectoralis major muscle but still enabling radical removal of the regional lymphnodes. the pectoralis major muscle was transected at its midportion to expose the thoracic wall for radical dissection of axillar and subclavicular lymphnodes followed by resuturing of the muscle to preserve its continuity. The parasternal nodes can also be dissected if necessary. The pectoralis minor muscle is either resected or preserved. This procedure should be applied mainly in T₁N₀ and T₁N_1a (Stage I in the TNM staging system) which seems recently to be increasing rapidly in number and for which the radical mastectomy with resection of pectoralis major muscle is thought to be too excessive. The procedure proposed in the present communication offers advantage not only in functional but also cosmetic aspect by preserving the pectoralis major muscle while the radicality of the oepration is retained. Although the number of cases thus treated is limited and the long-term follow up with survival rate is not yet available, the procedure seems to be of considerable value in selected patients.     

Modified radical mastectomy with preservation of the pectoralis major muscle.

A new technique of modified radical mastectomy for early breast cancer was devised with an express purpose of preserving pectoralis major muscle but still enabling radical removal of the regional lymphnodes. The pectoralis major muscle was transected at its midportion to expose the thoracic wall for radical dissection of axillar and subclavicular lymphnodes followed by resuturing of the muscle to preserve its continuity. The parasternal nodes can also be dissected if necessary. The pectoralis minor muscle is either resected or preserved. This procedure should be applied mainly in T1N0 and T1N1a (Stage I in the TNM staging system) which seems recently to be increasing rapidly in number and for which the radical mastectomy with resection of pectoralis major muscle is thought to be too excessive. The procedure proposed in the present communication offers advantage not only in functional but also cosmetic aspect by preserving the pectoralis major muscle while the radicality of the operation is retained. Although the number of cases thus treated is limited and the long-term follow up with survival rate is not yet available, the procedure seems to be of considerable value in selected patients.     

Anatomy of the pectoral nerves and their preservation in modified mastectomy

The upper part of the pectoralis major muscle is innervated by the medial pectoral nerve, whereas the lateral pectoral nerve supplies approximately the lower third of the muscle. The lateral pectoral nerve is closely associated with the pectoralis minor muscle, with its branches passing through or around the lateral margin of the muscle, or both. As a result, the nerve may be compromised during division, retraction or removal of the pectoralis minor muscle and during resection of the central and anterior lymph nodes. The medial pectoral nerve distributes with the thoracoacromial vessel branches, and both should be avoided during removal of the lymph nodes at the apex of the axillary space. Injury to the lateral pectoral nerve by accidental division or by evulsion produces variable postoperative atrophy, fibrosis and shortening of the lower third of the pectoralis major muscle, with limitation of shoulder motion and change in the cosmetic contour of the pectoral region of the chest. Routine removal of the pectoralis minor muscle and the lateral pectoral nerve as described by Patey and Handley during their modified mastectomy is not recommended because of the loss of innervation of the lower part of the pectoralis major muscle. The medial and lateral pectoral nerves described herein were named according to their anatomic position in the pectoral area. Furthermore, it is suggested that the use of the terms medial and lateral as applied to these pectoral nerves should denote their actual course, location and distribution and not perpetuate the confusing traditional practice of reversing the names of these nerves on the basis of their origin.     

腔镜乳腺癌改良根治术保留肋间臂神经的临床观察

目的：比较乳腺癌腔镜腋窝淋巴清扫与传统开放腋窝淋巴清扫在保留肋间臂神经（ICBN）方面的效果。 方法：选择拟行乳腺癌改良根治术,术中ICBN的乳腺癌I,II期患者46例,分为腔镜手术组（21例）和传统手术组（25例）。比较两组手术时间,术中出血量及术后并发症,术后对两组患者上臂内侧及腋窝感觉功能进行随访观察。 结果：腔镜组与传统组手术成功保留ICBN分别为20例（20/21）和23例（23/25）,两组成功率比较,差异无统计学意义（P=0.658）;与传统组比较,腔镜组腋窝清扫时间较长,而腋窝清扫出血量与术后并发症减少（P<0.001,P=0.029）;全组随访2~20个月,平均16个月,均未见复发,保留ICBN者,均无上臂及腋窝主观异样感觉症状。 结论：腔镜清扫腋窝淋巴结时,保留ICBN是可行的,并在减少出血量和术后并发症方面具有一定的优势。     

Predictors of Nipple Ischemia after Nipple Sparing Mastectomy

Nipple sparing mastectomy (NSM) has become an accepted approach in selected cases of breast cancer and prophylactic mastectomy. Various surgical techniques have been described and nipple ischemia has been a common complication. Potential risk factors for nipple ischemia after NSM are examined. To examine predisposing factors for nipple ischemia after NSM. Prospective evaluation of 71 consecutive NSM in 45 patients from 2009 to 2011 was performed. There were 40 mastectomies for cancer (56.3%), and 31 (43.7%) prophylactic mastectomies. In cases of cancer, the ducts were excised from the undersurface of the nipple. Reconstructive methods included: expander 58, latissimus flap/expander 2, implant 10, and free TRAM flap 1. Various patient and technical factors were examined for impact on nipple ischemia. Partial nipple necrosis occurred in 20 cases (28.2%). Nineteen cases healed uneventfully and one required secondary nipple reconstruction. Operations for cancer (OR 10.54, CI 1.88–59.04, p = 0.007) and periareolar incisions (OR 9.69, CI 1.57–59.77, p = 0.014) predisposed to nipple ischemia. Periareolar incisions and dissection of the nipple ducts for cancer have a higher risk of nipple necrosis after NSM.     

Nipple reconstruction

Creation of the nipple-areolar complex is the final and important component of the breast reconstruction process. Various techniques using a variety of local flaps are available. This article covers the pre- and postoperative care of the woman having nipple reconstruction, reviews the author's preferred techniques, discusses the use of supplemental materials for nipple augmentation, and comments on the common complications.