• Archives of Plastic Surgery
• /
• v.39 no.4
• /
• pp.384-389
• /
• 2012

Background Numerous procedures are available for nipple reconstruction without a single gold standard. This study presents a method for reducing donor-site morbidity in nipple reconstruction using a composite nipple graft after transverse rectus abdominis musculocutaneous flap breast reconstruction. Methods Thirty-five patients who underwent nipple reconstruction using a composite nipple graft technique between July of 2001 and December of 2009 were enrolled in this study. To reduce the donor site morbidity, the superior or superior-medial half dome harvesting technique was applied preserving the lateral cutaneous branch of the fourth intercostal nerves. The patients were asked to complete a previously validated survey to rate the color and projection of both nipples, along with the sensation and contractility of the donor nipple; and whether, in retrospect, they would undergo the procedure again. To compare projection, we performed a retrospective chart review of all the identifiable patients who underwent nipple reconstruction using the modified top hat flap technique by the same surgeon and during the same period. Results Thirty-five patients were identified who underwent nipple reconstruction using a composite nipple graft. Of those, 29 patients (82.9%) responded to the survey. Overall, we received favorable responses to the donor site morbidity. Projection at postoperative 6 months and 1 year was compared with the immediate postoperative results, as well as with the results of nipples reconstructed using the modified top hat flap. Conclusions The technique used to harvest donor tissue is important. Preserving innervation of the nipple while harvesting can reduce donor site morbidity.

• Archives of Plastic Surgery
• /
• v.34 no.5
• /
• pp.622-627
• /
• 2007

Purpose: Although the autogenous tissue transfer has been the mainstay of the breast reconstruction, concern for the donor site morbidity can lead to the superseded method using tissue expander with implant or permanent expander-implant. However, the additional procedure of tissue expansion possibly cause discomfort and raise the cost. We tried to verify the efficacy of using the saline-filled breast implant by itself for the safe and convenient immediate breast reconstruction modality if the patients have small, round and non-ptotic breasts and the sufficient breast skin can be saved with mastectomy. Methods: From July 2002 to July 2005, 29 breasts of 26 patients were restored only with the saline-filled breast implant immediately after the skin sparing or nipple-areolar skin sparing mastectomy in Asan Medical Center. A pocket with pectoralis major and serratus anterior muscle was created and the implant was covered with this muscle pocket. Simultaneous contralateral augmentation was performed in patients whose mastectomy specimen weighed less than 100g. Results: Using only the saline-filled breast implant resulted in the successful reconstruction with few complications including partial necrosis of nipple areolar skin (five cases, 17.2%), capsular contracture (three cases, 10.3%), hematoma (one case, 3.4%), depigmentation of areolar skin (one case, 3.4%), hypertrophic scar (one case, 3.4%), which were all healed by conservative management. There were no significant complications such as implant exposure and subsequent removal. Conclusion: Immediate breast reconstruction only with the saline-filled breast implant can be a satisfactory alternative option for the patients whose breast is small, round and non-ptotic, especially when the nipple-areolar skin of the breast is preserved in the mastectomy.

• Archives of Plastic Surgery
• /
• v.37 no.1
• /
• pp.87-90
• /
• 2010

Purpose: Mondor's disease is commonly known as a benign breast condition after augmentation mammaplasty, and some authors have also reported its association with other breast surgeries such as reduction mammaplasty or axillary lymph node biopsy. Here we report two cases of Mondor's disease after immediate breast reconstruction with silicone implant. Methods: Two women, 51-year-old and 36-year-old, underwent immediate breast reconstruction with silicone implants after nipple-areolar skin-sparing mastectomy. Results: Subcutaneous cord-like firm lesion appeared on upper abdomen, axillary area following surgery. The lesion was painless and spontaneously subsided with no medications. Conclusion: To our knowledge, this is the first report of Mondor's disease developed after immediate breast reconstruction using silicone implant.

• Archives of Plastic Surgery
• /
• v.41 no.4
• /
• pp.366-373
• /
• 2014

Background The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer. Methods We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision. Results 281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction. Conclusions Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.

• Archives of Plastic Surgery
• /
• v.38 no.5
• /
• pp.715-717
• /
• 2011

Purpose: In cases of breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy with nipple-areolar complex (NAC) removal, the flat contour of the flap's skin paddle can easily look unnatural and dissatisfying. Reconstructed NAC on the flap surface lacks the elevated contour that the normal areola possesses, resulting in an unnatural final result. Therefore, we would like to introduce a novel method to improve this problem and report the satisfactory results we obtained. Methods: Operations were conducted on 19 patients who underwent immediate breast reconstruction with a free TRAM flap and skin-sparing mastectomy from January 2009 to January 2010, with a mean follow-up of nine months. While the TRAM free flap was being inset, a purse-string suture was carried out on the dermal layer of skin flap to create a slight protrusion with Gore-$Tex^{(R)}$ sutures. Results: The elevated mound surrounding the NAC was well maintained for an average follow-up period of nine months. Nipple projection was also well maintained. There was no complaint about breast contour or nipple height reduction. In addition, there was no reported incidence of other complications. Conclusion: The purse-string suture technique presents a more natural breast silhouette around the NAC and helps to maintain nipple projection. Furthermore, it does not require any supplementary incisions or complicated skills. There has been no report of additional complications using this technique.

• Archives of Plastic Surgery
• /
• v.48 no.5
• /
• pp.483-493
• /
• 2021

Background Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes. Methods Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed. Results There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025). Conclusions Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

• Archives of Reconstructive Microsurgery
• /
• v.21 no.2
• /
• pp.118-130
• /
• 2012

Background: Women receiving mastectomy usually prefer a single-stage surgical procedure without the need for additional surgery. Hence, nipple sparing mastectomy was introduced, and the follow-up data on the aesthetic outcome and recurrence of breast cancer were investigated in this study. Materials and Methods: The study subjects comprised 22 patients who received nipple-sparing mastectomy and immediate breast reconstruction using the free transverse abdominal rectus abdominis myocutaneous flap between June of 2007 and June of 2012. The patients' aesthetic outcomes were measured with 2 methods for the objective result: Breast size measurements and breast volume calculation both at preoperative phase and postoperative 1 years phase. Also, the patients' satisfaction was evaluated at postoperative 1 year with the self-assessment questionnaire. Follow up check for assessing cancer recurrence was performed for an average period of postoperative 1063 days. Results: First, in objective aesthetic outcome, there were no significant differences between the preoperative and postoperative results on both the breast size and the volume. Second, the patient satisfaction analysis scores were graded as very good in 15 patients (68.2%), and as good in 6 patient (27.3%). Most of the patients were very satisfied with our surgery method. Last, there was no local or distant recurrence in these 22 patients during the follow-up period. Conclusion: In this study, the nipple-sparing mastectomy achieved satisfactory results for the breast scar and shape with a single-stage surgical procedure, and the cancer recurrence rate was not significantly different from that of the conventional mastectomy. Besides, the nipple-sparing mastectomy is more cost-effective than the conventional mastectomy since it reduces the need for additional procedures. However, we think that it is necessary to determine the long-term outcomes about the recurrence rate.

• Archives of Plastic Surgery
• /
• v.45 no.3
• /
• pp.229-238
• /
• 2018

Background Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. Methods All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. Results A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. Conclusions Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

• Archives of Reconstructive Microsurgery
• /
• v.23 no.2
• /
• pp.51-64
• /
• 2014

This study provides a systematic review of the literature on nipple-sparing mastectomy and necrotic complications in order to estimate the prevalence of necrotic complications and to investigate their significant predictors. A literature search was conducted using the MEDLINE and Ovid databases. A pooled analysis was performed for calculation of the prevalence of nipple-areolar complex (NAC) necrosis, mastectomy flap necrosis, and overall necrotic complications and to evaluate the relationships between necrotic complications and potential risk factors. A total of 44 papers were analyzed. The prevalence of overall necrotic complications was 13.7%, including 7.5% for NAC necrosis and 7.8% for mastectomy flap necrosis. Types of incisions showed significant association with the rates of NAC necrosis and mastectomy flap necrosis. Incisions involving the NAC showed a significantly higher rate of NAC necrosis than those not involving it. The prevalence of NAC necrosis was higher in the autologous tissue reconstruction group than in the prosthesis group. Active smoking and diathermy dissection were significant predictors of both NAC necrosis and mastectomy flap necrosis. The findings of this review suggest that there are several predictors of necrotic complications in nipple-sparing mastectomy. Appropriate patient selection, careful operative planning, and surgical technique refinements may reduce the risk of necrotic complications.

• Archives of Plastic Surgery
• /
• v.46 no.6
• /
• pp.535-543
• /
• 2019

Background A high incidence of breast animation deformity (BAD) has been reported following immediate breast reconstruction with subpectorally placed implants. The aim of this study was to assess and compare the incidence of BAD in women who underwent either subpectoral or prepectoral immediate breast reconstruction. Therefore, we developed a grading tool and tested its reproducibility in a clinical setting. Methods Video recordings of 37 women who had undergone unilateral or bilateral immediate breast reconstruction were evaluated by two consultant plastic surgeons. The degree of BAD was assessed by our grading tool, named the Nipple, Surrounding Skin, Entire Breast (NSE) grading scale, which evaluates the degree of tissue distortion in three areas of the breast. Blinded assessments were performed twice by each observer. Results Eighteen patients were reconstructed with subpectoral implant placement and 19 with prepectoral implant placement. Using the NSE grading scale, we found a significant difference in the degree of BAD between the groups, in favor of patients who underwent prepectoral immediate breast reconstruction (0.2 vs. 4, P=0.000). Inter- and intraobserver agreement was moderate (74%) to strong (88%). Conclusions The incidence and severity of BAD was significantly lower in women reconstructed with a prepectorally placed implant than in those who underwent subpectoral immediate breast reconstruction. All patients reconstructed using the subpectoral technique had some degree of BAD. The inter- and intraobserver agreements were high when using the NSE grading scale, suggesting it is an easy-to-use, reproducible scale for assessing BAD in women who undergo immediate breast reconstruction.