Annals of Surgical Oncology

, Volume 20, Issue 10, pp 3294–3302

Nipple Skin-Sparing Mastectomy is Feasible for Advanced Disease

Authors

    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
    • Arkansas Breast Cancer Act Breast Cancer Interdisciplinary Breast Fellowship
  • James Yuen
    • Division of Plastic Surgery, Department of SurgeryUniversity of Arkansas for Medical Sciences
  • Matthew Hardee
    • Department of Radiation OncologyUniversity of Arkansas for Medical Sciences
  • Pranjali V. Gadgil
    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
    • Arkansas Breast Cancer Act Breast Cancer Interdisciplinary Breast Fellowship
  • Chandan Das
    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
  • Ronda Henry-Tillman
    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
  • Daniela Ochoa
    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
  • Soheila Korourian
    • Department of PathologyUniversity of Arkansas for Medical Sciences
    • Division of Breast Surgical Oncology, Department of Surgery, Winthrop P. Rockefeller Cancer InstituteUniversity of Arkansas for Medical Sciences
    • Tenenbaum Breast Cancer Foundation
    • Fashion Footwear Association of New York (FFANY/QVC)
Breast Oncology

DOI: 10.1245/s10434-013-3174-4

Cite this article as:
Burdge, E.C., Yuen, J., Hardee, M. et al. Ann Surg Oncol (2013) 20: 3294. doi:10.1245/s10434-013-3174-4

Abstract

Background

Skin-sparing mastectomy (SSM) or nipple skin-sparing mastectomy (NSSM) are procedures commonly offered as part of the surgical treatment for breast cancer. Each involves a mastectomy with preservation of the skin overlying the breast (in SSM) and often also the skin overlying the nipple-areolar complex (NSSM). At the time of mastectomy, immediate reconstruction with a tissue expander or implant is performed for a more favorable cosmetic outcome. Until now, these procedures have been reserved for low-risk patients and are rarely offered to patients with advanced disease where neoadjuvant chemotherapy and postmastectomy radiation are a planned part of the treatment. We report our experience of SSM and NSSM in such high-risk patients.

Methods

This retrospective study from 2001 to 2012 evaluates the outcomes of 527 patients who underwent SSM or NSSM. Sixty patients with advanced disease who underwent neoadjuvant chemotherapy followed by SSM or NSSM with immediate reconstruction and subsequent radiotherapy (RT) were identified. The cosmetic and oncologic outcomes of this patient group were noted.

Results

A total of 527 patients in our study group had a total of 1,035 skin-sparing mastectomies (558 NSSM and 477 SSM; 444 patients with bilateral and 83 with unilateral procedures). Of the 60 patients with locally advanced disease, 39 underwent NSSM and 21 underwent SSM. All patients received RT to the diseased side. Mean age of the group was 50.2 ± 10.8 years, with a range of 27–75 years for NSSM and 29–73 years for SSM. The lymph node status was positive in 71.8 % with an average tumor size of 3.8 ± 2.5 cm. The overall radiation-induced complication rate was 38.1 % (8 of 21) in the SSM group and 30.8 % (12 of 39) in the NSSM group. Wound infections and tissue necrosis occurred at a rate of 16.7 %. The implant was removed in 5 % of these cases. Capsular contracture occurred at a rate of 10.2 %. Radiation-related nonbreast complications occurred in 6.7 % of the cases. Examples of these radiation-related nonbreast complications included radiation pneumonitis, stenosis of the superior vena cava requiring venoplasty and severe atypical chest pain thought to be consistent with osteochondritis. The locoregional recurrence rate (median follow-up of 18 months) was 14.3 % (3 of 21) in the SSM group and 10.3 % (4 of 39) in the NSSM group.

Conclusions

SSM and NSSM have been offered to patients with relatively low-risk breast cancer as oncologically safe while affording superior cosmesis with one-step immediate reconstruction. Our series demonstrates that either procedure can be offered to patients with more advanced cancers requiring postoperative RT. The complication rates are comparable to those reported for patients undergoing RT after traditional mastectomies.

Patients with breast cancer have experienced not only improved outcomes with advancements in treatment but also improvement in aesthetics as a result of developments in surgical and reconstruction techniques. Toth and Lappert1 were the first to describe skin-sparing mastectomy (SSM) followed by immediate breast reconstruction (IBR) in their seminal article. The breast tissue, nipple-areola complex (NAC), previous biopsy incisions, and skin overlying superficial tumors are removed from the breast during a SSM in an effort to maximize skin preservation and improve cosmetic outcome while facilitating reconstruction. IBR is simplified by preservation of the native breast skin envelope as well as the natural inframammary fold, affording the patient a more realistic and pleasing cosmetic result. The immediate advantage of SSM followed by IBR is the superior aesthetic result compared with either simple mastectomy with IBR or delayed reconstruction.2,3 The authors also surmised that IBR was more cost-effective than delayed reconstruction. Moreover, this surgical technique may provide substantial psychosocial benefits to most patient.46

Both SSM and (less commonly) nipple skin-sparing mastectomy (NSSM) are procedures offered as part of the surgical treatment for breast cancer. Each involves a mastectomy with preservation of the skin overlying the breast and also the skin overlying the NAC in a NSSM. At the time of mastectomy, immediate reconstruction is initiated with a tissue expander or completed with an implant for a more favorable cosmetic outcome.

Larger T2 tumors and nodal positivity are not contraindications to either a SSM or NSSM. In the absence of skin involvement by tumor, either can be oncologically safe.7 However, the role in the treatment of stage IIB or III breast cancer is debatable given the high probability of requiring postmastectomy radiotherapy (RT). Until recently, these procedures have been reserved for prevention in high-risk patients or early-stage node-negative breast cancer. Such procedures were rarely offered to patients with locally advanced disease where neoadjuvant chemotherapy and postmastectomy radiation are a planned part of the treatment. We hypothesized that locally advanced breast cancer treated with appropriate neoadjuvant chemotherapy and postoperative RT would have similar local control and cosmesis in patients with early-stage breast cancer. We report the cosmetic and oncologic outcomes of this patient group.

Methods

Study Population

This institutional review board (IRB)-approved retrospective study from 2001 to 2012 evaluates the outcomes of a subpopulation of 60 patients from 527 who underwent SSM or NSSM. Exclusion criteria included locally advanced disease with involvement of the skin, inflammatory breast cancer, collagen–vascular disease, and known smoking within the previous 6 months. Prior RT was not an exclusion, and four such patients were included. Sixty patients were identified with either locally advanced disease that underwent neoadjuvant chemotherapy followed by SSM or NSSM with immediate reconstruction and prior or subsequent RT.

Surgical Procedure

Incision Selection and Technique

Figure 1a depicts surgical incisions that have been used during these surgeries. For example, an elliptical or keyhole incision was used for overly pendulous breasts for which preservation of the NAC would not be cosmetically appealing. This incision gave the plastic surgeon the ability to create the final incision, which usually lay along the inframammary fold or alternatively a reduction mammoplasty scar (i.e., inverted-T incision), such that the final flap edges were fresh and less traumatized.
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Fig. 1

a Incision design: A NSSM (axillary), B SSM (elliptical), C SSM (lollipop), D NSSM (vertical radial), and E NSSM (inframammary). b Preferred vertical infra-areolar radial incision (VIA)

Our initial experience with NSSM was through an inframammary incision (Fig. 1a). However, our preferred incision, vertical infra-areolar (VIA), preserves all of the blood supply to the skin of the breast, thus resulting in fewer complications. Boneti et al.8 and Stolier et al.9 have previously report on complications with various incision types. This VIA incision extends from the areola limbus to the inframammary fold, variably extending from 4 to 8 cm in length, centered at the nipple in the sitting position (Fig. 1b).

The previous surgical scar was used as long as it provided appropriate access for the mastectomy. However, a new incision was made if the location of the scar would not provide adequate exposure. We found that a keyhole or lollipop incision provided excellent exposure in those patients in whom the NAC was excised.

NAC involvement, breast size, and ptosis are deciding factors when considering a SSM versus NSSM. Absence of NAC involvement by malignancy on clinical examination or preoperative imaging (i.e., mammography, ultrasound, or MRI) was sufficient evidence to proceed with a NSSM. The final determinant of a NSSM versus SSM was based intraoperatively on histologic assessment of the nipple core. Cases in which the intraoperative cytology was positive for malignancy were immediately converted to SSM, with subsequent removal of the NAC. Those with inconclusive or negative intraoperative assessment proceeded as a NSSM until the final pathology result confirmed malignant involvement. The NAC was removed at a second surgery when the final pathology indicated a positive nipple margin.

Sentinel Lymph Node Injection

Sentinel lymph node biopsy was indicated for all patients with invasive ductal carcinoma and for patients with ductal carcinoma-in situ (DCIS) that spanned more than 2.5 cm, was multifocal, high grade, or mass forming. Intraoperative subareolar injection of unfiltered technetium-99m sulfur colloid (Cardinal Health, Dublin, OH) was performed after induction of anesthesia, providing single-agent mapping with technetium-99m sulfur colloid.10 Earlier experience with methylene blue dye during SSM or NSSM has demonstrated significant risk of skin necrosis such that we no longer use it for sentinel lymph node mapping.11 However, isosulfan blue (Lymphazurium, Ben Venue Labs Inc., Bedford, OH) was used at our institution for axillary reverse mapping such that blue dye was injected into the volar surface of the upper arm to identify, map, and preserve the axillary lymphatics draining the arm.11

Mastectomy Procedure

The chosen incision (Fig. 1) was created using a number 10 blade. The skin flap dissection plane was identified and guided with serial dilations using Pratt cervical dilators of increasing caliber ranging from 16 to 44 F, as previously described by Boneti et al.8 (Fig. 2), thus maintaining a consistent skin flap thickness regardless of body habitus.
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Fig. 2

a Pratt dilators of varying caliber (13/15 to 41/43). bThin flaps development facilitated with the creation of the dissection plane using serial dilation. c Cribriform-like path of dissection

Skin flaps were elevated with electrocautery set in the cutting mode to prevent thermal injury. The NSSM or SSM borders of dissection were the same as for a standard simple mastectomy: superior to approximately the second rib; inferior to the rectus; medial to the sternum and lateral to the latissimus. Next, anterior dissection was performed, dissecting the breast and underlying pectoralis fascia away from the pectoralis major muscle. The skin overlying the NAC was transected free at the level of the dermis with a cold knife or scissors to avoid thermal injury. A nipple core biopsy was sent intraoperatively for cytology as previously described to exclude NAC involvement.12

The breast was delivered from the breast envelope en bloc, oriented for the pathologist, and the NAC marked with ink to facilitate identification by the pathologist. Botox and 0.5 % Marcaine were injected into the pectoralis major muscle, which we have previously demonstrated to reduce postoperative pain, decrease hospital stay, and facilitate postsurgical pectoral expansion.13

Reconstruction

Breast reconstruction was accomplished either immediately with implants or with expanders followed by delayed implants. We prefer immediate reconstruction with saline-filled implants or tissue expanders placed in a partial subpectoral pocket, using AlloDerm (Life Cell Corporation, Branchburg, NJ) to bridge the lateral and inferior edge of the pectoralis major muscle and the chest wall.14

Drains were placed in the space between the muscle and skin, and the surgical incisions were closed in two layers. Patients with ptotic breasts requiring skin resection or those with the desire to have larger breasts had tissue expander placement for postoperative tissue expansion. Patients who underwent reconstruction with tissue expanders underwent serial expansions over several months. The expanders were then exchanged for a definitive saline implant once the desired volume had been achieved and after RT, when it was a necessary part of treatment.

Cosmesis Rating

Cosmesis was assessed on subsequent clinic visits using a visual analog scale (1–10). A score of 10 was given by the patient and the surgeon when they believed that the neobreast approximated the original breast. When patients scored their neobreast better than 10, it was recorded as such; however, for statistical analysis, it was processed as a 10. Data for NSSM patients were abstracted from the chart and were last recorded at an average follow-up time of 18 months after RT.

Pathology

Each breast was examined using standard hematoxylin and eosin staining viewed under light microscopy and interpreted under the supervision of a staff pathologist. The additional breast margin overlying the tumor location, the NAC, and the posterior nipple–skin border were evaluated for evidence of malignancy.

Chemotherapy

Patients diagnosed with invasive breast cancer were referred to medical oncology. The decision for preoperative or postoperative chemotherapy was made in conjunction with a medical oncologist.

Radiotherapy

Five thousand units of external beam conformal radiation were administered to the total skin after all surgery and systemic therapies were completed for patients with original tumors larger than 5 cm and with 4 or more positive lymph nodes. Only patients who had no prior RT to the affected breast received RT to the diseased side.

Statistical Analysis

Patient demographics, tumor characteristics, type of surgery, lymph node status, postoperative complications, radiation-induced complications, wound infections, tissue necrosis, implant removal, capsular contracture, cosmesis, and recurrence were recorded in Microsoft Excel (Microsoft Corporation, Redmond, CA). Descriptive analysis and comparison between groups were conducted.

Results

Study Population

Of the 60 patients studied with locally advanced disease, 39 underwent NSSM and 21 underwent SSM. Only patients who had no prior RT to the affected breast received RT to the diseased side. Five patients had previously elected to undergo breast-conserving therapy and subsequently elected NSSM or SSM after a new diagnosis of DCIS. The mean age of the group was 50.2 ± 10.8 years, with a range of 27–75 years for NSSM and 29–73 years for SSM. Age was not significantly different between the SSM and NSSM groups (mean ± SD, 53.95 ± 10.46 and 48.1 ± 10.4 years, respectively). Postoperative follow-up was longer for the SSM group at 38.2 ± 26.3 months, while for NSSM it was 25.3 ± 18.8 months.

Surgical Procedure

A total of 527 patients in our study group underwent a total of 1,035 skin-sparing mastectomies (558 NSSM and 477 SSM; 444 patients with bilateral and 83 with unilateral procedures). Of the 60 patients with locally advanced disease, 39 underwent NSSM and 21 underwent SSM. Of the 39 RT population undergoing TSSM, 30 (76.9 %) underwent a vertical radial incision extending from the lower areola border to the inframammary crease. Eight (20.5 %) were accomplished through an inframammary incision (Fig. 1a), and 1 (2.6 %) was completed through a previous incision. Of the 29 RT population undergoing SSM 20 (95.2 %) were done through an elliptical keyhole incision, 7 (33 %) lollipop or teardrop-shaped incision, and 1 (4.8 %) through an inverted-T reduction mammoplasty incision.

Cosmesis Results

Cosmesis rating data for NSSM patients were abstracted from the chart and were last recorded at an average follow-up time of 18 months after RT. Women were asked to rate their cosmetic result on a visual analog scale from 0 to 10 in comparison to their preoperative breast. Data were available for 8 of 60 (13.3 %) of the patients. The average rating was 8 out of 10 by the patient and 9 out of 10 by the physician.

Pathology

In the NSSM + RT group, the indications for the mastectomies were invasive breast cancer in 87.2 % of the patients (34 of 39), with the most common identified as invasive ductal cancer in 28 (71.8 %) patients, invasive lobular cancer in 5 (12.8 %), and nonspecified invasive mammary cancer in 2 (5.1 %). DCIS was the new histological finding in 4 patients (10.3 %) who had previously elected breast-conserving therapy.

For the SSM + RT group, the indications for the mastectomies were invasive breast cancer in 95.2 % of the patients (20 of 21), with the most common histology being invasive ductal cancer in 14 (66.7 %) patients, invasive lobular cancer in 4 (19 %), and nonspecified invasive mammary cancer in 2 (9.5 %). DCIS was the histological finding in 1 patient (4.8 %) who had previously elected breast-conserving therapy.

Prechemotherapy tumor size was comparable in each group (3.4 ± 2.2 cm for NSSM vs. 4.6 ± 2.9 cm for the SSM group). Sentinel lymph node biopsy was performed in 55 cases; of these, 16 exhibited evidence of metastatic disease and were followed with an axillary node dissection. The lymph node status was positive in 71.8 % with an average tumor size of 3.8 ± 2.5 cm, or stage IIIA disease. The remaining 5 patients did not undergo sentinel lymph node biopsy because their pathology was low-grade DCIS.

Chemotherapy

A total of 60 patients received chemotherapy or hormone receptor therapy (i.e., with Tamoxifen or Arimidex), 47 as neoadjuvant chemotherapy and 13 postoperatively distributed between the NSSM (38 of 39) and SSM (19 of 21) groups. Patients with advanced disease were more likely to receive neoadjuvant therapy to down-stage the tumor and improve the potential cosmetic outcome.

Complications

Table 1 summarizes the observed overall radiation-induced complications. This overall rate was 30.8 % (12 of 39) in the NSSM group and 38.1 % (8 of 21) in the SSM group. Wound infections and tissue necrosis occurred at a rate of 16.7 %. The implant was removed in 5 % of these cases. Capsular contracture occurred at a rate of 10.2 %. Radiation-related nonbreast complications occurred in 6.7 % of the cases. Examples of these radiation-related nonbreast complications included radiation pneumonitis and stenosis of the superior vena cava requiring venoplasty and severe atypical chest pain thought to be consistent with osteochondritis.
Table 1

Summary of radiotherapy-induced complications

Characteristic

SSM

NSSM

Number of patients

21

39

Average tumor size (cm)

4.6 ± 2.9

3.4 ± 2.2

Overall RT-induced complication rate (breast related)

38.1 % (8/21)

30.8 % (12/39)

Locoregional recurrence ratea

14.3 % (3/21)

10.3 % (4/39)

Wound/tissue necrosis rate

16.7 % (10/60)

Implant removal rate

5 % (3/60)

Capsular contracture rate

10 % (6/60)

RT-induced complication rate (nonbreast related)

6.7 % (4/60)

SSM skin-sparing mastectomy, NSSM nipple skin-sparing mastectomy, RT radiotherapy

aMedian follow-up 18 months

Nine patients were smokers (15 %). Seven of those had delayed breast reconstruction after meeting our abstinence criteria of 6 months. Commonly, these patients underwent smoking cessation while they were receiving neoadjuvant chemotherapy. Two patients omitted the fact that they were smokers or passive smokers until after the operation and had immediate reconstruction, one with tissue expander and one with permanent saline implant. Of note is that no complications occurred in this unintended subgroup.

Recurrences

Locoregional recurrences (LRR) were observed in the skin, subcutaneous tissue of the neobreast, or regional lymph nodes in 10.3 % (4 of 39) of the NSSM and 14.3 % (3 of 21) of the SSM. There were no recurrences or occurrences involving the spared NAC or in the scar of the NSSM. Four of the 60 patients (6.7 %) receiving RT developed systemic recurrence (i.e., metastasis to the liver, cervical lymph nodes, or lumbar spine). One NSSM patient (1.7 %) developed both LRR and systemic disease within 18 months of surgery and was deceased 12 months later.

Discussion

It is well known that both immediate and delayed breast reconstruction after mastectomy provide substantial psychosocial benefits for women undergoing mastectomy for breast cancer.46 As early as 1991, Toth and Lappert experimented with the concept of sparing the skin of the breast as part of the mastectomy procedure for breast cancer.1 The breast tissue, NAC, previous biopsy incisions, and skin overlying superficial tumors are removed from the breast during a SSM in an effort to maximize skin preservation and improve cosmetic outcome while facilitating reconstruction.

Thorough review of the literature suggests that until recently, these procedures have been reserved for prevention in high-risk patients or early-stage node-negative breast cancer. Such procedures were rarely offered to patients with locally advanced disease where neoadjuvant chemotherapy and postmastectomy radiation are a planned part of the treatment. It is believed that T2 tumors and nodal positivity do not necessarily represent contraindications to SSM in relation to oncological safety.7 However, its role in the treatment of stage II or III breast cancer is debatable in the absence of extensive skin involvement by tumor and multifocality in view of the high probability of requiring postmastectomy RT. In our study, the average prechemotherapy disease was stage IIIA, and the tumor size was comparable in each group (3.4 ± 2.2 cm for NSSM vs. 4.6 ± 2.9 cm for the SSM group). Sentinel lymph node biopsy was performed in 55 cases; of these, 16 exhibited evidence of metastatic disease and were then treated with axillary node dissection. The lymph node status was positive in 71.8 % with an average tumor size of 3.8 ± 2.5 cm.

The chief concern with the procedure is the oncological safety for the patient; however, these issues for the most part have been laid to rest. Over the past two decades, investigators have confirmed the oncological safety of this technique.8,1524 SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for high-risk patients and early breast cancer despite the lack of randomized controlled trials and paucity of published data. The literature suggests that, as would be expected, the LRR is only 1–3 % in most series.2529 Moreover, the LRR for patients with T1, T2, and T3 tumors who underwent skin-sparing mastectomies was reportedly 3, 10, and 11 %, respectively.18,19,22 We found similar rates of LRR in our post-RT analyzed population, specifically 10.3 and 14.3 % for the NSSM and SSM groups, respectively.

Some authors reported many complications after IBR followed by RT.30 The most common complications were fat necrosis (16 %) and radiation fibrosis (11 %) in a study of immediate autologous IBR or transverse rectus abdominis myocutaneous (TRAM) reconstructions.31 Obviously the concern here is that fat necrosis leads to volume loss and hardening of the reconstructed breast—a concern especially when RT is administered after IBR. Therefore, in these cases of autologous tissue reconstructions, it has been suggested to delay the reconstruction until after the completion of RT. Conversely, other authors reported excellent outcomes after post-TRAM RT when delivery of RT was optimized using tangential fields and standard fractionation. Mehta and Goffinet32 describe their optimization technique, which included a customized bolus designed for the entire TRAM flap reconstructed chest wall. The bolus was designed to spare the central region of the reconstruction where the reconstructed nipple would be performed, and the customized bolus was applied on alternating days during the treatment. However, the bolus was applied daily in patients who received supplemental direct electron fields. The chest wall was prescribed 5,040 cGy in 28 fractions of 180 cGy. The supraclavicular field was prescribed 4,500 cGy in 25 fractions of 180 cGy. If supplemental electron fields were required to reduce the lung dose from the tangent beams, these were prescribed a dose of 4,500 cGy in 25 fractions of 180 cGy. Patients received treatment on either a 6 or 4 MV linear accelerator.32 Unfortunately, there are no randomized controlled studies on the effects of RT on autologous reconstructions, and most studies are at best heterogeneous, uncontrolled, and retrospective in nature.33

Investigations on the reconstructed breast with the use of implants, either alone or in conjunction with a flap reconstruction, found in particular that fibrosis and/or contracture often caused subsequent shrinkage of the reconstructed breast around the implant. Evans et al.34 compared 39 irradiated implant reconstructed breasts with 338 nonirradiated reconstructions and reported a significant negative effect on the implant reconstructed outcome. The principal complications were capsular contracture and postoperative pain, which led to 43 % of patients undergoing a subsequent capsulectomy. Clearly capsular contraction leads to poorer aesthetic results in many cases, often requiring additional flap surgery. This contracture rate and potential poor cosmesis has encouraged surgeons wishing to offer SSM their patients to recommend avoiding implant IBR when it is known that a patient is likely to require postoperative RT.30

A prospective analysis by McCarthy et al.35 evaluating unilateral postoperative chest wall RT in bilateral tissue expander/implant reconstructed patients observed that in general the degree of capsular contracture was higher on the irradiated side, yet overall symmetry, aesthetic results, and patient satisfaction remained high. Therefore, these observations give credence to the theory that IBR using tissue expansion and implants is an acceptable option for women undergoing mastectomy for breast cancer.35 Furthermore, capsule formation can be treated with capsulotomy or capsulectomy should the need arise. Interestingly, Cordeiro et al.36 reported that despite the higher incidence of complications associated with postreconstruction RT, the majority of their patients remained satisfied with their IBR. Granted, patient satisfaction was significantly higher among nonirradiated patients (67 vs. 88 %); however, 72 % of those who received RT said that they would again choose the same form of reconstruction.

Kronowitz et al.37,38 proved that the adverse effects of RT on SSM and IBR could be minimized through optimization of RT and by placing a subpectoral saline-filled tissue expander to facilitate delayed revision of reconstruction using an implant, an autologous flap with or without implant after removing the tissue expander. This then-novel concept, known as immediate-delayed reconstruction, was postulated to avoid the aesthetic and radiation-delivery problems that can occur after IBR.37

Acellular dermal matrix is being used with increasing frequency by surgeons during IBR to assist with tissue expander or implant-based primary breast reconstruction.14,39,40,51 Theoretically, this matrix provides a scaffold upon which and within which the patient’s own cells can repopulate and revascularize the implanted tissue. Various reconstructive techniques have demonstrated its utility, particularly in burn, abdominal wall, and breast reconstruction.4143 The use of acellular dermal matrix in breast reconstruction continues to be actively explored and will continue to evolve.39,4446

Antony et al.47 reported an overall complication rate of 23.6 %, with rates of 7.2 % for seroma, 2.0 % for hematoma, 3.9 % for cellulitis, 4.6 % for flap necrosis, and 3.3 % for infection in a study of 153 breast reconstructions. However, Rawlani et al.48 reported an overall complication rate of 16.5 %, with rates of 7.4 % for infection, 1.7 % for seroma, and 6.6 % for flap necrosis in their study of 121 breast reconstructions. They further noted an overall complication rate of 30.7 % in women who received adjunct breast RT, compared with 13.7 % in nonirradiated breasts. Unfortunately, few studies have compared and stratified differences in outcomes with respect to type of acellular dermis, body mass index, radiation exposure, or intraoperative expander fill. We found the overall radiation-induced complication rate to be 30.8 % (12 of 39) in the NSSM group and 38.1 % (8 of 21) in the SSM group. Wound infections and tissue necrosis occurred at a rate of 16.7 %. The implant was removed in 5 % of these cases. Capsular contracture occurred at a rate of 10.2 %. Radiation-related nonbreast complications occurred in 6.7 % of the cases.

Breuing and Colwell49 noted that despite a higher rate of complications, acellular dermal matrix-assisted tissue expander reconstructions appeared to resist RT effects much better than did standard tissue expander reconstructions. A similar phenomenon has been observed by a number of authors and is currently being explored in the literature.50,51

Boneti et al.8 in their analysis of 281 patients, determined that the preferred incision, VIA, preserved all of the blood supply to the skin of the breast, resulting in fewer complications. Moreover, they found the incidence of postoperative complications was equivalent among the various skin incisions (Fig. 1); however, the severity of skin loss was usually superficial with the VIA incision and much less than that observed with any of the other incisions. Of note is that Stolier et al.9 performed 82 NSSMs without NAC necrosis, and they also advocate a 6 o’clock radial incision as well (Fig. 1b), or a lateral incision if excising a biopsy sample or prior scar.

When compared to patients undergoing similar reconstructions procedures without being subjected to RT, we found an overall radiation-induced complication rate of 30.8 % (12 of 39) in the NSSM group and 38.1 % (8 of 21) in the SSM group. Boneti et al.8 reported an overall complication rate of 7.1 % (20 of 281) and 6.2 % (14 of 227) for NSSM and SSM groups, respectively. Therefore, one could conclude that the RT induced complication rate is 3-fold that of a nonirradiated population. Moreover, we found that wound infections and tissue necrosis occurred at a rate of 16.7 % in the RT group, while Boneti et al.8 observed a rate of 2.6 % in the nonirradiated group. Furthermore, they reported a capsular contracture rate of (0.01 %), while we found it occurred at a rate of 10.2 %.

It is important to note that the median follow-up in our study was merely 18 months, which may be considered extremely short by others and which may pose a significant limitation to our study.

Nevertheless, we hypothesized that locally advanced disease treated with appropriate neoadjuvant chemotherapy and postoperative RT would have similar local control and cosmesis to that of early breast cancer patients. The cosmetic and oncologic outcomes of this patient group are reported herein. Our series demonstrates that either a SSM or NSSM procedure can be offered to patients with more advanced cancers requiring postoperative RT. The complications rates are comparable to those reported for patients undergoing RT after traditional mastectomies. Moreover, we believe that our developed skin-sparing surgical technique and reconstruction methods using a tissue expander and/or implant coupled with an acellular dermal matrix sling, not solely relying on the native musculature, may prove beneficial to those patients requiring RT as an integral part of their cancer treatment and may be integral in quite possibly reducing scarring and contractures precipitated by RT after IBR.4951

Acknowledgment

Supported by the Arkansas Breast Cancer Act Breast Cancer Interdisciplinary Breast Fellowship (E. C. Burdge, P. Gadgil); the Tenenbaum Breast Cancer Foundation, Little Rock, AR (V. S. Klimberg); and by the Fashion Footwear Association of New York (FFANY/QVC) (V. S. Klimberg).

Disclosure

The authors report no disclosures or conflict of interest.

Copyright information

© Society of Surgical Oncology 2013