Anatomy and preservation of the nipple-areola complex / 国际外科学杂志

Preserving nipple-areola complex (NAC) in breast-conserving surgery and nipple-areola complex-sparing mastectomy (NSM) can achieve good tumor safety and breast aesthetics under the premise of appropriate case selection. However, there are still many doubts about the local anatomy of the nipple and NAC and how to preserve the NAC and reshape the shape of the nipple on the basis of selecting cases to achieve individualized treatment and complete tumor resection. In this paper, the NAC, internal nipple and posterior nipple anatomy are described in detail; Combined with the operation of NAC during NSM operation, the treatment of breast duct bundle inside the nipple and behind the nipple were introduced with author′s experience and pictures. The pathologic evaluation of preserving NAC, NAC conservation in breast cancer patients with nipple discharge and radiotherapy after NAC conservation were discussed. In fact, the current situation in our country is that too many patients may be suitable for immediate breast reconstruction or delayed breast reconstruction after NSM. It is very important to be familiar with the local anatomical characteristics of nipples and NAC for standardized breast conserving surgery and NSM. Therefore, more patients with breast cancer can safely retain NAC and breast, and breast reconstruction can be further accomplished on the basis of preserving NAC.

Surgical management of nipple areola complex in central breast cancer / 中华肿瘤杂志

Objective: To explore the surgical strategy of nipple areola complex (NAC) management in central breast cancer. Methods: A retrospective analysis was conducted on 164 cases of central breast cancer who underwent surgery treatment from December 2017 to December 2020 in the Breast Center of Beijing Tongren Hospital, Capital Medical University. Prior to the surgery, the tumor-nipple distance (TND) and the maximum diameter of the tumor were measured by magnetic resonance imaging (MRI). The presence of nipple invagination, nipple discharge, and nipple ulceration (including nipple Paget's disease) were recorded accordingly. NAC was preserved in patients with TND≥0.5 cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative intraoperative frozen pathological margin. All patients with signs of NAC involvement, TND<0.5 cm or positive NAC basal resection margin confirmed by intraoperative frozen pathology underwent NAC removal. χ(2) test or Fisher exact test was used to analyze the influencing factors. Results: Of the 164 cases of central breast cancer, 73 cases underwent breast-conserving surgery, 43 cases underwent nipple-areola complex sparing mastectomy (NSM), 34 cases underwent total mastectomy, and the remaining 14 cases underwent skin sparing mastectomy (SSM). Among the 58 cases of NAC resection (including 34 cases of total mastectomy, 14 cases of SSM, and 10 cases of breast-conserving surgery), 25 cases were confirmed tumor involving NAC (total mastectomy in 12 cases, SSM in 9 cases, and breast-conserving surgery in 4 cases). The related factors of NAC involvement included TND (P=0.040) and nipple invagination (P=0.031). There were no correlations between tumor size (P=0.519), lymph node metastasis (P=0.847), bloody nipple discharge (P=0.742) and NAC involvement. During the follow-up period of 12 to 48 months, there was 1 case of local recurrence and 3 cases of distant metastasis. Conclusions: For central breast cancer, data suggest that patients with TND≥0.5cm, no signs of NAC invasion (nipple invagination, nipple ulceration) and negative NAC margin in intraoperative frozen pathology should be treated with NAC preservation surgery, whereas for those with TND<0.5 cm or accompanied by signs of NAC invasion, NAC should be removed. In addition, nipple reconstruction can be selected to further improve the postoperative appearance of patients with central breast cancer.

Innovation and practice of endoscope-assisted nipple-sparing mastectomy combined with immediate subpectoral implant breast reconstruction without gas and mesh through small skin incisions / 中华内分泌外科杂志

Objective:To examine the feasibility and safety of endoscopic subcutaneous mastectomy and immediate reconstruction via a small skin incision approach without gas and mesh for early breast carcinomas.Methods:We analyzed 7 patients diagnosed with breast cancer who underwent an endoscopic subcutaneous mastectomy and immediate reconstruction from Jun. to Nov. 2021 using a gasless and meshless small skin incision approach at the Department of Thyroid and Breast Surgery, the First Affiliated Hospital of USTC. Mean age was 44.9 (29-63) years. Clinical stage, postoperative complications and other data of patients were collected. Patients were required to fill in BREAST-Q scale anonymously before and during postoperative follow-up. The difference was considered significant for P < 0.05. Results:The tumors were all unilateral and solitary lesions, with a mean diameter of 1.74 (0-5) cm. The average distance of mass from the nipple on imaging was 2.11cm (range 0 to 4) . Postoperative pathological clinical stage,1 patient was in Tis, 3 patients were in stage I, 2 patients were in stage II and a pathological complete response was achieved in one patient (ypT0pN0cM0 CR) . The mean operative time was 245.3 (195-316) min, the mean intraoperative bleeding volume was 37.1ml, the mean postoperative hospital stay was 5.1 d, and the median follow-up time was 8.8 (6-11.2) months. All the 7 patients had incision healing at the first stage, and no complications such as infection, incision complications, capsular contracture, nipple-areola complex or skin flap necrosis, removal or displacement of breast implant occurred. No local recurrence or metastasis was detected during the follow-up period. Compared with preoperative, the scores of postoperative psychosocial status, chest wall status were lower ( P<0.05) , but still ideal, while breast satisfaction and sexual satisfaction scores were not significantly different from preoperative baseline ( P>0.05) . Conclusion:This study indicates that endoscope-assisted breast reconstruction with gasless and meshless is a safe and feasible surgical intervention method for early breast cancer, with good cosmetic effects, and can be promoted as a new type of breast reconstruction.

Application of two-stage implant-based breast reconstruction after breast cancer surgery / 国际外科学杂志

Objective:To investigate the efficacy and clinical value of two-stage implant-based breast reconstruction after total mastectomy for breast cancer patients.Methods:Thirty-two patients with breast cancer, who underwent nipple-sparing mastectomy or skin-sparing mastectomy, primary skin expander implantation, and permanent implant replacement after radiotherapy from January 2018 to December 2020 in the Breast Center, Beijing Tongren Hospital, Capital Medical University were analyzed retrospectively. Record the operation time of the patient, the interval between replacement surgery and radiotherapy, prosthesis volume, the difference between the volume of 0.9% sodium chloride solution in the dilator and the volume of the prosthesis, the retention time of the postoperative drainage tube, the satisfaction of the breast shape and the complications after the replacement.Results:The average operation time was (67.81±19.71) min; the average time interval between replacement surgery and radiotherapy was (9.88±2.00) months; the average volume of 0.9% sodium chloride solution in the dilator was (225.47±56.83) mL, and the average prosthesis volume was (259.06±70.88) mL, the average difference between the volume of the prosthesis and the volume of 0.9% sodium chloride solution in the dilator was (33.59±14.88) mL; the volume of the prosthesis is increased by an average of (13.65±5.19)% compared with the dilator; the average time of drainage tube retained after the operation was (9.03±1.40) d; satisfaction with breast shape after replacement: excellent in 23 cases (71.9%), general in 8 cases (25.0%), poor in 1 case (3.1%); postoperative complications: incision fat liquefaction 1 case of dehiscence (3.1%), 2 cases of seroma (6.3%), no serious complications such as external exposure and removal of the prosthesis.Conclusions:For patients with breast cancer, who need breast reconstruction after mastectomy, the two-stage implant-based breast reconstruction in which the replacement operation will be carried out more than 6 months after radiotherapy is safe. Moreover, achieve better symmetry and aesthetic effect by releasing the capsule, reconstructing the inframammary fold, and necessary plastic surgery of the contralateral breast.

Paget’s disease of the breast: a case series

Paget’s disease of the nipple is a rare disease with a rather bizarre presentation which makes the diagnosis easily missed. Three cases are presented here with different modes of presentation and histological findings. A biopsy provided the definitive diagnosis in the three patients and the treatments offered was based on the histological findings - modified radical mastectomy and simple mastectomy for invasive carcinoma and carcinoma in-situ respectively.

Bilateral idiopathic granulomatous mastitis a rare benign inflammatory disease of breast: case report

Idiopathic Granulomatous Mastitis (IGM) is an uncommon benign inflammatory disorder of breast. Peri-ductal mastitis is thought to be the initial inflicting factor for its development. IGM usually presents as painful swelling, abscess or sinus/fistula in breast. There are no specific findings on ultrasound or mammographic imaging, and moreover it looks BIRADS-IV on mammography. Histopathology provides the final diagnosis. Here authors report a case of bilateral IGM which was successfully treated with surgery.

Research progress in breast blood supply and breast reduction / 中国修复重建外科杂志

Objective: To review the research on distribution of the nerve and blood supply of breast, and the development of breast reduction in recent years. Methods: The related literatures about the distribution of the nerve and blood supply of breast, the development of breast reduction, and postoperative lactation function in recent years were reviewed extensively. The above aspects were analyzed and summarized in combination with the author's experiences. Results: With the anatomical study of mammary gland, nipple areola complex nerve distribution and blood supply, breast reduction has been developed rapidly, and a variety of surgical methods have been formed. But each has its own advantages and disadvantages, and its indications are different. Through the application and improvement of the auxiliary examination technique, severe complications such as nipple areola complex necrosis reduce obviously after operation. Through the selection of position of the incision and pedicle, the degree of retaining the pedicle glands, the application of auxiliary liposuction technique, and the improvement of suture technique, the scar of incision reduces, the sensation of nipple areola is preserved more, and a more satisfactory breast shape is obtained. Some of the patients who gave birth after breast reduction have lactation function. Conclusion: There are some shortcomings in various surgical methods at present, individualized surgical methods should be adopted according to the characteristics of the patients. Further research is needed on how to preserve more sensation of nipple areola, obtain a good and lasting breast shape, and preserve lactation function of women after operation.

Safety of oncology after immediate breast reconstruction for breast cancer patient / 中国实用外科杂志

Immediate breast reconstruction can reduce the psychological trauma of breast loss while preventing patients from undergoing secondary surgery.However,oncologists must ensure tumor safety when choosing immediate breast reconstruction.Careful preoperative evaluation and adequate intraoperative glandectomy are the prerequisites to ensure oncologic safety.The National Comprehensive Cancer Network(NCCN) guidelines clearly states that inflammatory breast cancer is a contraindication to immediate breast reconstruction.In addition,for patients who plan to receive postoperative radiotherapy,immediate breast reconstruction should be carefully selected.Despite the lack of high-level evidence-based evidence,available data show that immediate breast reconstruction does not affect postoperative adjuvant chemotherapy.It is safe and reliable for some patients to choose the subcutaneous gland resection that retains nipples and areola.Lymphoma after prosthesis implantation has been reported,but the incidence is low.Therefore,breast reconstruction immediately after mastectomy is a safe and reliable surgical procedure in suitable patients with breast cancer.

Protection and technical key points of nipple-areola complex in breast reconstruction / 中国实用外科杂志

Traditional mastectomy requires the removal of nipple-areola complex(NAC),no matter whether the subsequent reconstruction or not,it can't meet the aesthetic needs of patients.With the development of breast reconstruction technology,immediate breast reconstruction with preservation of nipple-areola complex has superior aesthetic effect.More and more breast cancer patients can maintain the integrity and beauty of their body after operation.How to better protect the nipple-areola complex in breast reconstruction surgery has become one of the focuses of breast surgeons.The operator should have a strong sense of NAC protection,carefully grasp the characteristics of the posterior mammary duct and blood supply of NAC,reasonably design the surgical incision,and reduce the occurrence of postoperative nipple ischemia,necrosis and other complications as far as possible.

Oncological safety and prognosis factors analysis of immediate breast reconstruction after nipple-areola-complex sparing mastectomy / 中华肿瘤杂志

Objective@#To explore the oncological safety of immediate breast reconstruction after nipple-areola complex(NAC) sparing mastectomy(NSM+ IBR) in patients with early stage breast cancer, and to analyze the prognostic factors of NSM+ IBR.@*Methods@#From January 2004 to December 2015, the clinical data of 118 cases of stage Ⅰ-ⅡA breast cancer who had undergone NSM+ IBR in Tianjin Tumor Hospital were collected, comparing with 75 cases of Ⅰ-ⅡA breast cancer patients who had undergone immediate breast reconstruction after modified radical mastectomy (MRM+ IBR) at the same period. In addition to the prognosis of these two groups, the prognostic factors were also retrospectively analyzed.@*Results@#The median follow-up were 53 months in the NSM+ IBR group and 51 months in the MRM+ IBR group, respectively. In the NSM+ IBR group, local recurrence, distant metastasis, death and NAC necrosis occurred in 4, 6, 9 and 4 cases during 3 years after operation, respectively. The local recurrence rate (LRR) was 3.4%, 3-year disease-free survival (DFS) rate was 91.5%, and the overall survival (OS) rate was 92.4%. In the MRM+ IBR group, local recurrence, distant metastasis, and death occurred in 1, 4, and 3 cases during 3 years after operation, respectively. The LRR was 1.3%, 3-year DFS was 93.3%, whereas the OS rate was 96.0%. No statistical difference was noted between the two groups (all P>0.05). That HER-2 positive and molecular type correlated with the 3-year DFS (P<0.05) independently and molecular type correlated with OS (P<0.05) independently in the NSM+ IBR group.@*Conclusions@#NSM does not impair patients′ prognosis and could ensure oncological safety of patients with early stage breast cancer. IBR could improve female patients′ figure and ensure the quality of life. HER-2 status and molecular type are the independent prognostic factors of the 3-year DFS. Molecular type is the independent prognosis factor of OS.

Analysis of nipple-areola blood supply in patients with breast hypertrophy and normal population / 中华整形外科杂志

Objective@#To explore the nipple-areola complex blood supply mode in hypertrophic breasts, and to obtain the pertinent knowledge of vascular anatomy for breast reduction surgery as well as the analysis of similarities and differences between hypertrophic and normal breasts. Comparing the blood supply of nipples-areola complex between these two groups for analyzing their similarities and differences.@*Methods@#Three dimensional reconstruction of the arteries in breast were performed in 50 patients between September 2015 and August 2017 with breast hypertrophy by computed tomographic angiography (CT angiography). The distribution pattern and the source direction of each main blood vessel was observed, counted and analyzed. Then, the data of breast hypertrophy patients were compared with the previous data about nipple-areola blood supply in normal population (the definition of main vessel: entering the breast gland or reaching the nipple-areola surrounding area, and diameter larger than 1 mm). Statistical description was taken for comparison.@*Results@#135 main vessels were observed in 100 breasts (50 patients). They mainly originate from the internal thoracic artery (69, 51.1%), lateral thoracic artery (37, 27.4%) and thoracoacromial artery(16, 11.9%), as well as a small amount from the brachial artery (7, 5.2%) and axillary artery(6, 4.4%). No main supply vessels from the posterior intercostal artery have been found. The patterns of breast blood supply varied among individuals, and high asymmetry ratio in the same individual was also observed. The internal superior (left: 30.7%, right: 34.2%) and superior lateral quadrant (Left: 29.2%, Right: 20%) of the breast was the most likely area for the main vessel to pass, followed by the breast lateral (Left: 16.9%, Right: 18.5%), lower inner (Left: 4.6%, Right: 5.7%), central (Left: 4.6%, Right: 4.2%), and superior (Left: 1.5%, Right: 2.8%). Differences existed in main vessels between normal breasts and hypertrophic breasts, either for source arteries or the distribution of breast. There was no main blood supply from the intercostal arteries or across the outer inferior quadrant.@*Conclusions@#The blood supply of the nipple-areola is not completely consistent between the hypertrophic breast and the normal size breast, and the blood supply pattern of the hypertrophic breasts is complex and diverse. CT angiography might be used before breast reduction surgery for clarifying the direction of the main vessels, so as to preserve more blood supply for nipple-areola, and to prevent nipple-areola necrosis.

The clinicopathologic factors associated with nipple-areola complex involvement in breast cancer / 中国癌症杂志

Nipple-areola complex-sparing mastectomy (NSM) is a surgical procedure that allows the preservation of the skin and nipple-areola complex (NAC) in mastectomy. The use of NSM for breast cancer is still controversial. The appropriate standard for selecting patients with low risk of NAC involvement has not been well established. The clinicopathologicity characteristics of primary tumor (e.g., tumor-to-nipple distance, tumor location, tumor size, multicentricity, lymph node metastasis, lymphovascular invasion, grade, HER-2 status) have been reported to be associated with NAC involvement. Clinical evaluation of NAC, retroareolar tissue biopsy and evaluation of clinicopathologic characteristics of primary tumor are helpful to patient selection in current clinical practice of NSM. Further studies are still needed to establish uniform selection criteria for NSM in breast cancer patients.

Incision choice of nipple-areola complex-sparing mastectomy / 中国癌症杂志

With the development of surgical techniques, the use of nipple-areola complex (NAC)-sparing mastectomy (NSM) has been increasing. Except for oncologic safety, the aesthetic outcome of surgery is greatly concerned by clinicians and patients. So far, there has been no consensus on the incision of NSM. This article reviewed the literature so as to provide some evidence for the selection of NSM incision.

Vascular anatomy and evaluation of the nipple-areola complex in nipple-sparing mastectomies / 中国癌症杂志

Nipple-areola complex (NAC)-sparing mastectomies (NSM) have gained acceptance in the ifeld of breast oncology. The superior aesthetic outcomes of NSM explain their increased use and rising popularity. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complication rates. An understanding of the NAC vascular anatomy is, therefore, clinically relevant beyond NSM. In this paper, the relevant clinical anatomy is described, mainly focusing on the anatomy of the NAC. This article also covers how to identify and classify the in vivo blood supply to the NAC using breast MRI exams which provide valuable information for assessing vascular anatomy of the NAC. This includes the arterial iflling phase, venous drainage phase and 3-dimensional reconstructed maximum intensity projection (MIP) images. Finally, the indocyanine green (ICG) and a specialized infrared camera-computer system provide surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to reduce the risk of nipple ischemia and necrosis.

The role of radiotherapy in nipple-areola complex-sparing mastectomy for patients with breast cancer / 中国癌症杂志

The technique of nipple-areola complex (NAC)-sparing mastectomy (NSM) facilitates the breast reconstruction due to preserving the skin and NAC of breast in the treatment of breast cancer. Key issues still remain controversial in NSM, in terms of the role of radiotherapy combined with NSM and sequence of radiotherapy and NSM, which arise from the consideration of the oncology safety. Some investigations addressed that post-NSM external beam irradiation and intra-operative radiotherapy (IORT) combined with NSM could reduce the local recurrence rate. Based on the appropriate patient selection and good quality of surgery, radiotherapy would be applied in different strategies of combination with NSM according to the risk of local recurrence of the cancer.

Pigmented Superficial Basal Cell Carcinoma of the Nipple-areola Complex / 대한피부과학회지

Basal cell carcinoma, which characteristically develops on sun-exposed areas such as the head and neck, is the most common cutaneous malignancy. The most important risk factor associated with its development is chronic ultraviolet light exposure, and basal cell carcinomas in non-sun-exposed areas are, therefore, rare. In particular, the nipple-areola complex is an extremely rare site for basal cell carcinomas, and only three cases involving this area have been reported in Korea to date. Here, we report the case of a 66-year-old woman with pigmented superficial basal cell carcinoma in the nipple-areola complex. Typical dermoscopic findings were obtained in this case.

Clinical application of lateral thoracic wall adipofascial flap in immediate mammoplasty / 中华内分泌外科杂志

Objective To explore the operative indication , therapeutic effects and feasibility of immedi-ate mammoplasty with lateral thoracic steato-fascia flap.Methods A retrospective study was carried out on clini-copathologic data of 26 patients receiving nipple-areola complex preserving modified radical mastectomy and im-mediate mammoplasty with lateral thoracic wall adipofascial flap and 5 patients receiving segmental mastectomy and immediate mammoplasty with lateral thoracic wall adipofascial flap because of benign breast diseases .In these patients receiving nipple-areola complex preserving modified radical mastectomy , 22 patients received lateral tho-racic wall adipofascial flap , and 4 patients received lateral thoracic wall adipofascial flap combined with silicone prosthesis .The surgical complications and cosmetic effects were evaluated by both subjective and objective stand -ard postoperatively .Results 24 patients were satisfied with the appearance of their breasts and the two sides seemed to be symmetrical .There was no flap or nipple necrosis .The patients received adjuvant chemotherapy after surgery.No local recurrence or distant metastasis occurred during the follow up (2 to 12 months).Five patients with benign breast diseases were very satisfied with their breast appearance after surgery .Conclusion For patients in early stage breast cancer receiving modified radical mastectomy with nipple-areolar complex preserved and patients with benign breast diseases having segmental mastectomy , immediate mammoplasty with lateral thoracic wall adipo-fascial flap is a good method which can help to keep well breast apperance without additional incision , and it is also economical , feasible , and can reduce patients'psychological pressure due to loss of the breast .

Poland Syndrome: A Case Study

We report a rare case of Poland syndrome in a 22-year-old female patient. This is a syndrome defined bytheunilateral absence or hypoplasia of the thoracic muscles with under development of one breast. A female patient presented with aesthetic concerns having hypoplasia of left breast and the nipple-areola complex small and displaced laterally. There were no other developmental problems with ribs, breast bone or upper extremity. The patient was surgically treated with breast reconstruction using amammary prosthesis. The incidence of Poland syndrome ranges from 1 in 7000 to 1 in 1,00,000 [Fokin and Robicsek (2002). Ann Thorac Surg 2002;74(6):2218–25]. Ten percent of these patients also express some of the other features of the disorder. There is a male to female ratio of 2:1 to 3:1.

Immediate breast construction using prosthesi after nipple-areola-sparing mastectomy in 26 cases / 肿瘤研究与临床

Objective To investigate the effect of immediate breast construction using prosthesi after nipple-areola-sparing mastectomy.Methods The immediate breast construction using prosthesi after nippleareola-sparing mastectomy was performed in 26 cases with breast cancer from January 2008 to December 2011 in Jiangsu Cancer Hospital.The postoperative cosmetic results and the complications were observed.The therapeutic effects were followed up.Results All operations were successful.The s,uperior rate of cosmetic result after one month according to JCRT was 88.5 ％ (23/26).No severe complication was found.After a median follow-up of 26 months (range 3-48 months),there was no recurrence and metastasis.Conclusion The immediate breast construction using prosthesi after nipple-areola-sparing mastectomy is maneuverable with satisfactory aesthetic result and the clinical effect,which deserves the further clinical application.

Nipple-areola complex preseving modified radical mastectomy and immediate breast reconstruction with latissimus dorsi fat flap for early breast cancer / 中华内分泌外科杂志

ObjectiveTo discuss the benefits of nipple-areola complex(NAC) preseving radical modified mastectomy and immediate reconstruction with latissimus dorsi fat flap for early breast cancer. MethodsFrom Jan 2006 to Dec 2008, 16 patients underwent NAC preseving modified radical mastectomy and immediate breast reconstruction with latissimus dorsi fat flap.ResultsAll patients recovered smoothly.No fat flap or back skin necrosis happened.The reconstructed breasts had good apperance with 93.8％ satisfaction rate.During the follow-up of 44 months (ranging from 36 to 60 months), all patients were disease-free.ConclusionsThe operation of NAC preseving modified radical mastectomy and immediate reconstruction with latissimus dorsi fat flap is safe and effective.It can improve the life quality of patients by satisfing the needs of both beauty and tumor resection.