• Korean Journal of Radiology
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• v.24 no.7
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• pp.640-646
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• 2023

Objective: Prospective studies on postoperative residual breast tissue (RBT) after robotic-assisted nipple-sparing mastectomy (R-NSM) for breast cancer are limited. RBT presents an unknown risk of local recurrence or the development of new cancer after curative or risk-reducing mastectomies. This study investigated the technical feasibility of using magnetic resonance imaging (MRI) to evaluate RBT after R-NSM in women with breast cancer. Materials and Methods: In this prospective pilot study, 105 patients, who underwent R-NSM for breast cancer at Changhua Christian Hospital between March 2017 and May 2022, were subjected to postoperative breast MRI to evaluate the presence and location of RBT. The postoperative MRI scans of 43 patients (age, 47.8 ± 8.5 years), with existing preoperative MRI scans, were evaluated for the presence and location of RBT. In total, 54 R-NSM procedures were performed. In parallel, we reviewed the literature on RBT after nipple-sparing mastectomy, considering its prevalence. Results: RBT was detected in 7 (13.0%) of the 54 mastectomies (6 of the 48 therapeutic mastectomies and 1 of the 6 prophylactic mastectomies). The most common location for RBT was behind the nipple-areolar complex (5 of 7 [71.4%]). Another RBT was found in the upper inner quadrant (2 of 7 [28.6%]). Among the six patients who underwent RBT after therapeutic mastectomies, one patient developed a local recurrence of the skin flap. The other five patients with RBT after therapeutic mastectomies remained disease-free. Conclusion: R-NSM, a surgical innovation, does not seem to increase the prevalence of RBT, and breast MRI showed feasibility as a noninvasive imaging tool for evaluating the presence and location of RBT.

• Archives of Plastic Surgery
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• v.46 no.1
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• pp.79-83
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• 2019

Robotic surgery facilitates surgical procedures by employing flexible arms with multiple degrees of freedom and providing high-quality 3-dimensional imaging. Robot-assisted nipple-sparing mastectomy with immediate reconstruction is currently performed to avoid breast scars. Four patients with invasive ductal carcinoma underwent robot-assisted nipple-sparing mastectomy and immediate robot-assisted expander insertion. Through a 6-cm incision along the anterior axillary line, sentinel lymph node biopsy and nipple-sparing mastectomy were performed by oncologic surgeons. The pectoralis major muscle was elevated, an acellular dermal matrix (ADM) sling was created with robotic assistance, and an expander was inserted into the subpectoral, sub-ADM pocket. No patients had major complications such as hematoma, seroma, infection, capsular contracture, or nipple-areolar necrosis. The mean operation time for expander insertion was 1 hour and 20 minutes, and it became shorter with more experience. The first patient completed 2-stage prosthetic reconstruction and was highly satisfied with the unnoticeable scar and symmetric reconstruction. We describe several cases of immediate robot-assisted prosthetic breast reconstruction. This procedure is a feasible surgical option for patients who want to conceal surgical scars.

• Archives of Plastic Surgery
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• v.42 no.3
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• pp.302-308
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• 2015

Background In the literature on nipple-sparing mastectomy (NSM) with one-stage immediate implant reconstruction, contralateral symmetrisation has drawn little attention, with many surgeons still performing standard cosmetic mammaplasty procedures. However, standard implant-based mammaplasty usually does not result in proper symmetry with the mastectomy side, especially regarding breast projection, overall shape, and volume distribution. Methods We retrospectively reviewed 19 consecutive patients undergoing unilateral NSM with immediate prosthetic reconstruction and contralateral simultaneous symmetrisation by using the tailored reduction/augmentation mammaplasty technique between June 2012 and August 2013. Results The average follow-up time was 13 months (range, 10-24 months). No major complications, such as infection, haematoma, and nipple-areola complex necrosis, were experienced. Conclusions Our experience suggests that simultaneous contralateral symmetrisation with tailored reduction/augmentation mammaplasty after unilateral immediate implant reconstruction after NSM facilitates durable and pleasant symmetric outcomes.

• Archives of Plastic Surgery
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• v.48 no.2
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• pp.194-198
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• 2021

Robot-assisted nipple-sparing mastectomy with immediate reconstruction is currently performed in an attempt to seek smaller and indistinct incisions. Robotic surgery system has been evolving under the concept of minimal invasive technique which is a recent trend in surgery. One of the latest version is the da Vinci SP Surgical System (Intuitive Surgical). In this report, we will share our experiences. Two patients underwent robot-assisted nipple-sparing mastectomy, each followed by immediate robot-assisted expander insertion and prepectoral direct-to-implant breast reconstruction, respectively. There was no open conversion or major postoperative complication. One patient experienced mild infection, which was resolved by intravenous antibiotic treatment. Simple docking process, multi-joint instruments, and thirdarm functionality are among the new surgical system's advantages. The present cases suggest that robot-assisted nipple-sparing mastectomy with immediate reconstruction using the da Vinci SP Surgical System is feasible and safe. The promising features and potential application of da Vinci SP in breast reconstruction need further study.

• Archives of Plastic Surgery
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• v.49 no.5
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• pp.580-586
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• 2022

Background Appropriate position of the nipple-areolar complex (NAC) is crucial following nipple-sparing mastectomy (NSM). The prevention of NAC malposition in two-stage implant-based breast reconstruction has not been well described, and the efficacy of the techniques has not been evaluated. This study aimed to evaluate the efficacy of our technique to prevent NAC malposition in patients who underwent implant-based breast reconstruction after NSM. Methods Patients who underwent two-stage implant-based breast reconstruction with NSM between January 2012 and December 2019 were included. We used a surgical technique to fix the NAC to the rigid base, assuming a pocket-like appearance, with pectoralis major muscle and lateral adipofascial flap at the time of tissue expander (TE) insertion. Patients were classified into two groups based on the performance of the technique for the prevention of NAC malposition. Results In 35 patients who underwent implant-based breast reconstruction after NSM, the clavicle-to-nipple distance ratio was 96.0±5.0% in those who underwent NAC fixation and 86.1±11.5% in those who did not undergo NAC fixation. Conclusions Using our technique, NAC malposition could be prevented in two-stage implant-based breast reconstruction. NAC fixation during TE insertion was found to be extremely effective. This procedure successfully prevented NAC malposition without the formation of extra scars.

• Archives of Plastic Surgery
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• v.34 no.5
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• pp.622-627
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• 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
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• v.37 no.6
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• pp.749-757
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• 2010

Purpose: Since skin sparing mastectomy removes the mammary gland and the nipple-areolar complex preserving all mammary skin, it makes the widespread use of implants in immediate reconstruction. This article reports our experience in immediate breast reconstruction after skin sparing mastectomy by using the silicone implants in patients especially who have small to moderate sized and minimal ptotic breast. Methods: From September of 2007 to July of 2009, we performed breast reconstruction for 44 breasts of 40 women with silicone implant after mastectomy. Tumors were divided into 5 malignant types (21 IDC, 18 DCIS, 2 ILC, 2 phylloides tumor, 1 mucinous carcinoma). The implant is placed in a submuscular pocket or in a submuscularsubfascial pocket depending upon the condition of the muscles and skin flaps after mastectomy. Results: The mean age was 47 years and the average follow-up period was 11 months. Cosmetic outcome was assessed by evaluation of photographs and assessment of breast volume and shape, breast symmetry, and overall outcome. About 80% of each of these parameters was scored as good or excellent. Breast complication was developed in a total of 6 cases including 2 capsular contracture, 2 partial skin necrosis due to blue dye injection and 2 implant infection. Conclusion: The use of definitive implants in a skin sparing mastectomy is a one-stage immediate breast reconstruction with low morbidity and acceptable result. This method is considered reliable with favorable aesthetic result.

• Archives of Plastic Surgery
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• v.43 no.4
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• pp.328-338
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• 2016

Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4-156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.

• Archives of Plastic Surgery
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• v.48 no.5
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• pp.483-493
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• 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 Plastic Surgery
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• v.38 no.5
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• pp.715-717
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• 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.