J Breast Cancer.  2019 Dec;22(4):641-646. 10.4048/jbc.2019.22.e52.

Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast

• Kim EK
• Cho JM
• Lee JW

• KMID: 2470900
• DOI: http://doi.org/10.4048/jbc.2019.22.e52

Abstract

Nipple-areolar skin-sparing mastectomy followed by autologous reconstruction in patients with large, ptotic breasts often offers a limited field, resulting in strenuous traction. Skin-sparing mastectomy (SSM) with immediate nipple grafting from the specimen was attempted for such patients. Patients who underwent SSM with immediate autologous breast reconstruction and nipple grafting between September 2016 and February 2019 were evaluated, including 33 nipple grafts in 30 patients. The average weight of the mastectomy specimen was 552.5 g and the average operation time for unilateral mastectomy was 109 minutes. No complete nipple loss or major skin flap necrosis was reported. Adjuvant therapy started after an average of 24 days. SSM with immediate nipple grafting on the autologously reconstructed breast could be an alternative for large, ptotic breasts. It is also useful for patients requiring contralateral balancing procedures or those with bilateral breast cancer in which only one nipple can be spared oncologically.

Keyword

Breast neoplasms; Free tissue flaps; Mammaplasty; Subcutaneous mastectomy

MeSH Terms

Breast Neoplasms
Breast*
Female
Free Tissue Flaps
Humans
Mammaplasty
Mastectomy*
Mastectomy, Subcutaneous
Necrosis
Nipples*
Skin
Traction
Transplants*

Figure

• 

  Figure 1 The procedure of immediate nipple grafting and the progression of graft survival (A) After completion of skin-sparing mastectomy, the nipple-areolar complex was separated from the specimen, and the nipple was severed. Frozen biopsy samples were obtained from the base. (B) The center of the flap skin paddle was de-epithelized to a diameter of 1 to 1.5 cm. (C) Composite nipple graft was sutured using 5-0 absorbable sutures in a simple interrupted manner with slightly greater tension than typical skin sutures. (D) Nipple was typically pale on the second postoperative day. (E) Congestion developed 7 days after surgery.

• 

  Figure 2 Follow up photographs of our patients. (A) A 50-year-old female patient had diffusely spreading ductal carcinoma in situ on her left breast. Skin-sparing mastectomy with immediate nipple grafting and free DIEP flap reconstruction was done. Postoperative 11 months photograph, after completion of tattooing. (B) A 62-year-old female patient with ductal carcinoma in situ on her left breast underwent skin-sparing mastectomy with immediate nipple grafting and free TRAM flap reconstruction. Postoperative six months photograph, before tattooing. (C and D) A 61-year-old female patient with invasive ductal carcinoma with microcalcifications on her left breast underwent skin-sparing mastectomy (560 g) with immediate nipple grafting, and immediate reconstruction was done by free TRAM flap with contralateral mastopexy. Pre- and 6 months post-operative clinical photographs. DIEP = deep inferior epigastric perforator; TRAM = transverse rectus abdominis musculocutaneous.

Reference

1. Ito H, Ueno T, Suga H, Shiraishi T, Isaka H, Imi K, et al. Risk factors for skin flap necrosis in breast cancer patients treated with mastectomy followed by immediate breast reconstruction. World J Surg. 2019; 43:846–852.

2. Frey JD, Salibian AA, Karp NS, Choi M. The impact of mastectomy weight on reconstructive trends and outcomes in nipple-sparing mastectomy: progressively greater complications with larger breast size. Plast Reconstr Surg. 2018; 141:795e–804e.

3. Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg. 2013; 132:1043–1054.

4. Carlson GW, Chu CK, Moyer HR, Duggal C, Losken A. Predictors of nipple ischemia after nipple sparing mastectomy. Breast J. 2014; 20:69–73.

5. Yang SJ, Eom JS, Lee TJ, Ahn SH, Son BH. Recipient vessel selection in immediate breast reconstruction with free abdominal tissue transfer after nipple-sparing mastectomy. Arch Plast Surg. 2012; 39:216–221.

6. Frey JD, Choi M, Salibian AA, Karp NS. Comparison of outcomes with tissue expander, immediate implant, and autologous breast reconstruction in greater than 1000 nipple-sparing mastectomies. Plast Reconstr Surg. 2017; 139:1300–1310.

7. Mastroianni M, Lin AM, Smith BL, Austen WG Jr, Colwell AS. Nipple loss following nipple-sparing mastectomy. Plast Reconstr Surg. 2016; 138:24e–30e.

8. Dent BL, Chao JW, Eden DJ, Stone BV, Swistel A, Talmor M. Nipple resection and reconstruction after attempted nipple-sparing mastectomy. Ann Plast Surg. 2017; 78:28–34.

9. van Verschuer VM, Mureau MA, Gopie JP, Vos EL, Verhoef C, Menke-Pluijmers MB, et al. Patient satisfaction and nipple-areola sensitivity after bilateral prophylactic mastectomy and immediate implant breast reconstruction in a high breast cancer risk population: nipple-sparing mastectomy versus skin-sparing mastectomy. Ann Plast Surg. 2016; 77:145–152.