Necrotic Complications after Nipple- and Areola-Sparing Mastectomy
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- Komorowski, A.L., Zanini, V., Regolo, L. et al. World J. Surg. (2006) 30: 1410. doi:10.1007/s00268-005-0650-4
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The objective was to analyze the frequency and factors influencing necrotic complication in female patients undergoing nipple- and areola-sparing mastectomy.
Summary and background data
Nipple- and areola-sparing mastectomy has recently been shown to yield satisfactory results in a carefully selected group of breast cancer patients. The technique includes extensive undermining of the nipple–areola complex, which may result in an increased rate of necrotic complications. We report our early experience with necrotic changes after nipple- and areola-sparing mastectomy.
The medical records of 38 patients undergoing nipple- and areola-sparing mastectomy were analyzed retrospectively.
Mean age of the patient was 44.5 years (range 26–65). Necrotic complications occurred in 15.8% of patients and included: skin flap necrosis (1 case), partial nipple–areola complex necrosis (2 cases), and complete nipple–areola complex necrosis (3 cases). Two cases of capsular contraction were also recorded. Statistical analysis showed age below 45 years to be associated with a lower risk of necrotic complications (OR 4.51, P < 0.05).
The nipple- and areola-sparing mastectomy, although resulting in a relatively high frequency of necrotic complications, is a valuable surgical option for patients with small, peripheral tumors and for women undergoing prophylactic mastectomy. The procedure seems to be safer for women under 45 years of age.
In the group of breast cancer patients with small breasts or an unfavorable lesion volume to breast volume ratio the cosmetic outcome of breast-conserving therapy can be unsatisfactory. Recent studies have shown that in a carefully selected group of patients skin-sparing mastectomy with preservation of the nipple–areola complex is an oncologically safe procedure.1,2 Since the rationale for nipple- and areola-sparing mastectomy is the improvement in postoperative breast cosmesis the necrotic complications of extensively undermined skin flaps and nipple–areola complex are of utmost importance. We present our early experience with necrotic complications in the group of 38 women undergoing nipple-sparing mastectomy.
We identified all women who underwent nipple-sparing mastectomy at the Department of Breast and Reconstructive Surgery at the Fondazione Salvatore Maugeri in Pavia, Italy from January 16, 2001 to November 5, 2004. The follow-up time ranged from 6 to 52 months. The retrospective analysis of the medical records of 38 female patients was performed taking into account age at diagnosis, stage of disease, preoperative chemotherapy, type of procedure performed, and surgical site complications.
For statistical analysis logistic regression was used. The level of significance was set at 0.05. Age strata were created.
Patients aged below 45 years
Patients aged 45 years or more
Sentinel lymph node procedure
Axillary dissection (complete)
Axillary dissection after SNB
Mastectomy was completed in all patients. Patients with preoperative diagnosis of metastatic disease in the axilla underwent complete axillary dissection. Access to the axilla was accomplished by a separate incision. Patients with the diagnosis of malignant breast disease without preoperative diagnosis of axillary involvement underwent a sentinel node procedure with peritumoral injection of radiocolloid. In patients with positive sentinel nodes, axillary dissection followed. All patients underwent immediate breast reconstruction with implantation of a breast prosthesis or a tissue expander. The patients had the implant irrigated with antibiotic solution at the time of subpectoral placement.
Number of patients
Complete nipple–areola necrosis
Partial nipple–areola necrosis
Necrotic complications overall
Statistical analysis showed that age of45 years or over had a significant impact on the risk of occurrence of necrotic complications (OR 4.51, 95% CI: 0.83–0.98; P < 0.05). Patients who underwent a sentinel node procedure were found to have a slightly increased risk of necrotic complications (borderline significance—OR 0.69; 95% CI: 0.11–1.01; P = 0.06). No other statistically significant relationships were noticed.
Recent results showed that areola-sparing mastectomy is an oncologically safe procedure for selected patients.3 A low incidence of areolar involvement (0.9%) can be associated with a high rate of nipple involvement (10.6%), as described by Simmons et al.4 The incidence of nipple involvement can reach up to 50% for tumors measuring more than 4 cm or located closer than 2 cm from the nipple.5 However, in a subset of patients with lesions located non-centrally and more than 2 cm from the nipple it has been shown that preservation of both nipple and areola can be performed with good oncological results, i.e., with a 5% rate of local recurrences at a mean of 59 months’ follow-up.1 Attempts at saving the nipple–areola complex in a group of patients with small peripheral tumors are therefore justified. Although in the presented group there were 2 patients with stage III disease, we do not recommend this procedure for patients with advanced disease. A large number of cases of stage II disease found in our study can be attributed to upstaging when positive sentinel node procedures have been carried out. However, the main criteria for nipple- and areola-sparing mastectomy remain tumor size, tumor location, and breast size.
Since the main rationale for nipple- and areola-sparing mastectomy is better postoperative breast cosmesis, all local complications that negatively influence the aesthetic outcome of the procedure are a serious concern. The technique of nipple- and areola-sparing mastectomy requires extensive undermining of the nipple–areola complex in order to achieve complete excision of glandular tissue. Extensive dissection might jeopardize the blood supply of the nipple–areola complex, and thus lead to necrotic changes. Moreover, immediate breast reconstruction is known to increase wound complications.6
In the reported series 7.9% (3 patients) developed complete necrosis of the nipple–areola complex and needed surgical intervention. Another 2 patients suffered from a transitory superficial slough of the nipple–areola complex (5.2%) and 1 patient (2.6%) developed mastectomy flap necrosis. In other published series of nipple-sparing mastectomy, the percentages of patients with necrotic complications are lower at 0%7 to 3.7%8 with complete nipple–areola necrosis and 6.7%7 to 7.4%8 with transitory or partial necrotic changes.
Crowe et al.7 suggested that a lateral incision for nipple- and areola-sparing mastectomy may contribute to nipple–areola complex viability. We were unable to support this hypothesis in our series. In our material only younger age proved to have positive impact on the nipple–areola complex viability. Interestingly, performing the sentinel node procedure was of borderline statistical significance for the occurrence of necrotic complications.
We did not observe any infectious complications, even though all patients underwent immediate breast reconstruction. The short follow-up period in the presented group of patients does not allow us to draw any conclusions with regard to oncological safety and total incidence of capsular contracture.
We believe that even with the total rate of necrotic complications of 15.8% after nipple- and areola-sparing mastectomy observed in our series, the operation is a very interesting option for a selected group of patients with non-advanced, peripherally located tumors, and for women undergoing prophylactic mastectomy. We showed the nipple-sparing procedure to be safer for women aged 44 and less.
This work has been supported by a UICC International Cancer Technology Transfer Fellowship and with Federal funds from the National Cancer Institute, National Institutes of Health, under Contract NO2-CO-91012.