Long-Term Outcomes in Prepectoral versus Subpectoral Two-Stage Implant-Based Breast Reconstruction after Nipple-Sparing Mastectomy.

BACKGROUND: Implant-based breast reconstruction remains the most often used method following mastectomy, but data are lacking regarding differences in complications and long-term patient-reported outcomes for two-stage subpectoral versus prepectoral reconstruction. This study sought to better understand the risks and impact of these reconstructive approaches on overall satisfaction. METHODS: Patients who underwent unilateral or bilateral nipple-sparing mastectomy and two-stage implant-based reconstruction from 2014 to 2019 were identified from the electronic medical records and contacted via email to complete the BREAST-Q survey. Overall satisfaction was measured by the question, "How happy are you with the outcome of your breast reconstruction?" using a six-point Likert scale. Patients were grouped into subpectoral or prepectoral cohorts. Complications were evaluated retrospectively. Only patients who were at least 6 months from their final reconstruction were included in the analysis. RESULTS: Of the 582 patients contacted, 206 (35%) responded. The subpectoral ( n = 114) and prepectoral ( n = 38) groups did not differ significantly by demographic or treatment characteristics. BREAST-Q scores were also comparable. Complication rates were similar, but prepectoral patients had a significantly higher rate of capsular contracture (16% versus 4%, P < 0.05). Bivariate ordered logistic regression identified prepectoral implant placement, having any postoperative complication, and capsular contracture as predictors of less overall happiness. CONCLUSIONS: The authors' study suggests that prepectoral patients may have slightly higher complication rates but are as satisfied as subpectoral patients after at least a year of follow-up. Further studies should investigate risk factors for capsular contracture, how the risk changes over time, and how the risk affects patient satisfaction.

Complications After Total Skin-Sparing Mastectomy and Expander-Implant Reconstruction: Effects of Radiation Therapy on the Stages of Reconstruction.

BACKGROUND: Many patients undergoing total-skin sparing mastectomy (TSSM) and 2-staged expander-implant (TE-I) reconstruction require postmastectomy radiation therapy (PMRT). Additionally, many patients undergoing TSSM for recurrent cancer have a history of lumpectomy and radiation therapy (XRT). Few studies have looked at the impact of XRT on the stages of TE-I reconstruction. METHODS: Patients undergoing TSSM and immediate TE-I reconstruction between 2006 and 2013 were identified from a prospectively maintained database. Rates of TE-I loss and severe infection requiring intravenous antibiotics were compared in patients with prior XRT (85 cases) and PMRT (133 cases). Complications were divided by stage of reconstruction: first stage (TSSM and TE placement) and second stage (TE-I exchange). RESULTS: Mean follow-up time was 2.5 years. Patients with prior XRT had more complications after the first stage of reconstruction than the second (TE-I loss: 15% vs 5%, P = 0.03; infection: 20% vs 8%, P = 0.04). Patients receiving PMRT had low complication rates after the first stage, when they had not yet received radiation (TE-I loss: 2%; infection: 5%). However, complication rates after TE-I exchange (TE-I loss, 18%; infection, 31%) were significantly higher, and nearly 4-fold higher than patients with prior XRT. CONCLUSIONS: Patients with prior XRT are at high risk for complications after the first stage of TE-I reconstruction after TSSM; however, the risk of complications at the second stage is comparable to patients without radiation exposure and significantly lower than patients receiving PMRT. Patients receiving radiation therapy should be given appropriate preoperative counseling regarding their risks.

Brief Report: Interleukin-17A-Dependent Asymmetric Stem Cell Divisions Are Increased in Human Psoriasis: A Mechanism Underlying Benign Hyperproliferation.

The balance between asymmetric and symmetric stem cell (SC) divisions is key to tissue homeostasis, and dysregulation of this balance has been shown in cancers. We hypothesized that the balance between asymmetric cell divisions (ACDs) and symmetric cell divisions (SCDs) would be dysregulated in the benign hyperproliferation of psoriasis. We found that, while SCDs were increased in squamous cell carcinoma (SCC) (human and murine), ACDs were increased in the benign hyperproliferation of psoriasis (human and murine). Furthermore, while sonic hedgehog (linked to human cancer) and pifithrinα (p53 inhibitor) promoted SCDs, interleukin (IL)-1α and amphiregulin (associated with benign epidermal hyperproliferation) promoted ACDs. While there was dysregulation of the ACD:SCD ratio, no change in SC frequency was detected in epidermis from psoriasis patients, or in human keratinocytes treated with IL-1α or amphiregulin. We investigated the mechanism whereby immune alterations of psoriasis result in ACDs. IL17 inhibitors are effective new therapies for psoriasis. We found that IL17A increased ACDs in human keratinocytes. Additionally, studies in the imiquimod-induced psoriasis-like mouse model revealed that ACDs in psoriasis are IL17A-dependent. In summary, our studies suggest an association between benign hyperproliferation and increased ACDs. This work begins to elucidate the mechanisms by which immune alteration can induce keratinocyte hyperproliferation. Altogether, this work affirms that a finely tuned balance of ACDs and SCDs is important and that manipulating this balance may constitute an effective treatment strategy for hyperproliferative diseases. Stem Cells 2017;35:2001-2007.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction.

INTRODUCTION: Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction. METHODS: All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature. RESULTS: Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively). CONCLUSIONS: Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.

Tissue Expander Reconstruction After Total Skin-Sparing Mastectomy: Defining the Effects of Coverage Technique on Nipple/Areola Preservation.

BACKGROUND: Total skin-sparing mastectomy (TSSM) has become increasingly frequent in recent years, as inclusion criteria continue to expand. Options for tissue expander coverage in these patients include complete submuscular tissue expander coverage and acellular dermal matrix (ADM)-assisted coverage. This study compares both techniques with regard to relevant outcomes, during a recent 1-year period at our institution. METHODS: All women undergoing TSSM and immediate expander placement between January 2012 and January 2013 were prospectively tracked. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of expansion, and incidence of complications were analyzed. RESULTS: In 1 year, 127 patients underwent TSSM on 202 breasts. Overall, 113 expanders underwent submuscular coverage, and 89 underwent ADM-assisted coverage. Mean intraoperative fill volume was 52 mL in the submuscular cohort and 205 mL in the ADM cohort (P = 0.0001). Mean tissue expander size was 404 mL in the submuscular cohort and 454 mL in the ADM cohort (P = 0.0002). χ analysis demonstrated no differences between the cohorts in incidence of complications, including partial/complete nipple necrosis. CONCLUSIONS: The use of ADM for expander coverage after TSSM allowed for greater initial expander fill. With large and ptotic breasts, this allows for reduced incidence of skin folds in the preserved breast skin pocket, and greater control over final nipple position, as the amount of loose, mobile skin is reduced by the greater initial fill. The safety profile of ADM use after TSSM is equivalent to that of submuscular coverage, with no differences in partial or complete nipple necrosis.

Expanding the Indications for Total Skin-Sparing Mastectomy: Is It Safe for Patients with Locally Advanced Disease?

BACKGROUND: Indications for total skin-sparing mastectomy (TSSM) continue to expand. Although initially used only for early-stage breast cancer, TSSM currently is offered in many centers to patients with locally advanced disease. However, despite this practice change, limited data on oncologic outcomes in this population have been reported. METHODS: A retrospective review of a prospectively collected database of all patients undergoing TSSM and immediate reconstruction from 2005 to 2013 was performed. The outcomes for patients with stage 2b and stage 3 cancer were included in the analysis. The primary outcomes included the development of locoregional or distant recurrences. RESULTS: Of 753 patients undergoing TSSM, 139 (18 %) presented with locally advanced disease. Of these 139 patients, 25 (18 %) had stage 2b disease, and 114 (82 %) had stage 3 disease. Most of the patients (97 %) received chemotherapy (77 % neoadjuvant, 20 % adjuvant), whereas 3 % received adjuvant hormonal therapy alone. Of the neoadjuvant patients, 13 (12 %) had a pathologic complete response (pCR) to treatment. During a mean follow-up period of 41 months (range 4-111 months), seven patients (5 %) had a local recurrence, 21 patients (15.1 %) had a distant recurrence, and three patients (2.2 %) had simultaneous local and distant recurrences. None of the local recurrences occurred in the preserved nipple-areolar complex skin. CONCLUSIONS: Patients with locally advanced breast cancer are most at risk for distant rather than local recurrence, even after TSSM. When used in conjunction with appropriate multimodal therapy, TSSM is not associated with an increased risk for local recurrence in this population, even in the setting of low pCR rates.

Comparison of Mammographic Findings Following Oncoplastic Mammoplasty and Lumpectomy Without Reconstruction.

BACKGROUND: Reconstruction of lumpectomy defects with reduction mammoplasty techniques can improve aesthetic outcomes and patient satisfaction. However, one concern with the substantial tissue rearrangement required is the possible difficulty with mammographic follow up and/or increased recommendations for future biopsies. METHODS: We performed a retrospective review of 49 patients who underwent oncoplastic reduction mammoplasty between 2001 and 2009 who were age-matched to patients who underwent lumpectomy without reconstruction. Mammography reports at 6 months, 1, 2, and 5 years postoperatively were reviewed for predominant findings, Breast Imaging Reporting and Data System final assessments, and recommendations for biopsy. RESULTS: There was no significant difference in abnormal mammographic findings prompting biopsy between the two cohorts at 6 months, 2 years, and 5 years postoperatively (p > 0.05). Biopsy rates over the 5-year period did not differ significantly between the two cohorts [9 (18 %) lumpectomy cohort, 12 (24 %) oncoplastic cohort, p = 0.46]. Overall cancer-to-biopsy ratio was 33 % in the lumpectomy cohort and 42 % in the oncoplastic cohort (p = 1.00). CONCLUSIONS: Although substantial tissue rearrangement is performed at the time of oncoplastic reduction mammoplasty, our results reveal no increased incidence of postoperative mammographic abnormalities or unnecessary biopsies compared to lumpectomy alone. This demonstrates that fear of increasing mammographic abnormalities and biopsies after reduction mammoplasty is unfounded and should not prevent utilization of this technique if it can optimize cosmetic outcomes and extend the option of breast conservation.

Negative Genetic Testing Does Not Deter Contralateral Prophylactic Mastectomy in Younger Patients with Greater Family Histories of Breast Cancer.

BACKGROUND: Increasing rates of contralateral prophylactic mastectomy (CPM) correlate with adoption of total skin-sparing mastectomy (TSSM). We aimed to characterize patients with unilateral breast cancer who underwent TSSM with CPM or without CPM (No CPM). METHODS: We reviewed all patients with unilateral breast cancer who underwent TSSM from 2006 to 2013. Trends in CPM and genetic testing were evaluated across time. Patient characteristics and complications were compared between CPM and No CPM groups. RESULTS: We identified 591 patients (293 No CPM and 298 CPM) with median follow-up of 25 (interquartile range [IQR] 13-52) months. All patients with deleterious mutations and 58% of those who tested negative for mutations underwent CPM. In patients who tested negative for mutations, CPM was correlated with younger patient age, greater family history, and younger age of relatives diagnosed with breast/ovarian cancer. CPM was associated with an increased risk of superficial nipple necrosis (relative risk [RR] 2.1, 95% confidence interval [CI] 1.12-4.0), wound breakdown (RR 1.62, 95% CI 1.04-2.5), and infections requiring oral antibiotics (RR 1.59, 95% CI 1.16-2.2). In patients with tissue expander/implant reconstruction, CPM was associated with an increased risk of implant exposure (RR 1.95, 95% CI 1.03-3.7) but did not affect the risk of implant loss (RR 0.91, 95% CI 0.56-1.48). CONCLUSIONS: Patients who choose CPM fit the profile of patients with higher risk of contralateral breast cancer (CBC), which may be due to polygenic risk factors that are currently under investigation. Physicians should address patients' fears of CBC, screening concerns, and the risk of complications when considering CPM.

Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment.

BACKGROUND: The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes. METHODS: Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed. RESULTS: The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025). CONCLUSIONS: Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes.

BACKGROUND: Radiation therapy is increasingly used in breast cancer therapy. With total skin-sparing mastectomy and nipple/areola complex preservation, defining the risks of various treatment regimens for morbidity is important, in the setting of immediate prosthetic reconstruction. The authors assessed the effects of premastectomy and postmastectomy radiation therapy on outcomes in total skin-sparing mastectomy and immediate prosthetic reconstruction. METHODS: All patients undergoing total skin-sparing mastectomy and immediate prosthetic reconstruction at the authors' institution between 2006 and 2012 were identified. Cohort 1 included patients undergoing total skin-sparing mastectomy and reconstruction with no radiation. Cohort 2 included patients with a prior history of radiation before total skin-sparing mastectomy and reconstruction. Cohort 3 included patients undergoing radiation after total skin-sparing mastectomy and reconstruction. RESULTS: A total of 580 patients underwent 903 breast reconstructions following total skin-sparing mastectomy. Cohort 1 included 727 breasts, cohort 2 included 63 breasts, and cohort 3 included 113 breasts. Any radiation delivery caused an increased rate of infection requiring antibiotics (21.6 percent, p = 0.00) and an increased risk of expander/implant loss (18.75 percent, p = 0.00). Cohort 2 had a higher risk of wound breakdown (p = 0.012). All cohorts showed similar low rates of nipple/areola necrosis. CONCLUSIONS: Both preoperative and postoperative radiation following total skin-sparing mastectomy and immediate prosthetic reconstruction result in higher, but acceptable, complication risks. Complications related to nipple/areola preservation are similar to those in nonradiated patients and in those undergoing skin-sparing mastectomy. Thus, nipple/areola complex preservation is safe in women undergoing radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Randomized trial of drain antisepsis after mastectomy and immediate prosthetic breast reconstruction.

BACKGROUND: In this 2-site randomized trial, we investigated the effect of antiseptic drain care on bacterial colonization of surgical drains and infection after immediate prosthetic breast reconstruction. METHODS: With IRB approval, we randomized patients undergoing bilateral mastectomy and reconstruction to drain antisepsis (treatment) for one side, with standard drain care (control) for the other. Antisepsis care included both: chlorhexidine disc dressing at drain exit site(s) and irrigation of drain bulbs twice daily with dilute sodium hypochlorite solution. Cultures were obtained from bulb fluid at 1 week and at drain removal, and from the subcutaneous drain tubing at removal. Positive cultures were defined as ≥1+ growth for fluid and >50 CFU for tubing. RESULTS: Cultures of drain bulb fluid at 1 week (the primary endpoint) were positive in 9.9 % of treatment sides (10 of 101) versus 20.8 % (21 of 101) of control sides (p = 0.02). Drain tubing cultures were positive in 0 treated drains versus 6.2 % (6 of 97) of control drains (p = 0.03). Surgical site infection occurred within 30 days in 0 antisepsis sides versus 3.8 % (4 of 104) of control sides (p = 0.13), and within 1 year in three of 104 (2.9 %) of antisepsis sides versus 6 of 104 (5.8 %) of control sides (p = 0.45). Clinical infection occurred within 1 year in 9.7 % (6 of 62) of colonized sides (tubing or fluid) versus 1.5 % (2 of 136) of noncolonized sides (p = 0.03). CONCLUSIONS: Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains, and reduced drain colonization was associated with fewer infections.

Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes.

BACKGROUND: Total skin-sparing mastectomy (TSSM) with preservation of the breast and nipple-areolar complex (NAC) skin was developed to improve aesthetic outcomes for mastectomy. Over time, indications for TSSM broadened and our technique has evolved with a series of systematic improvements. METHODS: We reviewed all cases of TSSM with immediate breast reconstruction performed from 2005 to 2012. Patient comorbidities, treatment characteristics, postoperative complications, and outcomes were obtained prospectively and through medical chart review. Locoregional recurrences, distant recurrences, and patient survival were analyzed with Kaplan-Meier methods. RESULTS: During this 8-year period, 633 patients (981 cases) underwent TSSM with median follow-up time of 29 (interquartile range 14-54) months. Immediate breast reconstruction was performed with tissue expander placement (89 %), pedicle TRAM (5 %), free flap (5 %), permanent implant (0.3 %), or latissimus flap (0.2 %). The incidences of postoperative complications decreased significantly over time. In 2012, these were down to 3.5 % for superficial nipple necrosis, 1.0 % for complete nipple necrosis, 3.0 % for minor skin flap necrosis, 4.4 % for major skin flap necrosis, 13.3 % for infections requiring oral antibiotics, 9.9 % for infections requiring intravenous antibiotics, 3.4 % for infections requiring operative intervention, and 8.5 % for expander/implant. Overall 5-year cumulative incidences of recurrence were 3.0 % (locoregional) and 4.2 % (distant), and there were no recurrences in the NAC skin. CONCLUSIONS: Systematic changes in our technique of TSSM and immediate breast reconstruction have decreased postoperative complications over time. Oncologic outcomes of locoregional and distal recurrences remain similar to skin-sparing mastectomy techniques.

Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with postmastectomy radiation therapy.

Given the high complication rates in patients who require radiation therapy (XRT) after mastectomy and immediate reconstruction, and the low local recurrence rates following neo-adjuvant chemotherapy and breast conservation therapy, we sought to determine if using neo-adjuvant chemotherapy and oncoplastic mammoplasty as an alternative to mastectomy and immediate reconstruction is an effective strategy for reducing complication rates in the setting of XRT. A prospectively maintained data base was queried for patients who received neo-adjuvant chemotherapy and XRT between 2001 and 2010 and underwent either oncoplastic mammoplasty or mastectomy with immediate reconstruction. Rates of postoperative complications between groups were compared using Fisher's exact test. Outcomes from 37 patients who underwent oncoplastic mammoplasty were compared to 64 patients who underwent mastectomy with immediate reconstruction. Mean follow-up was 33 months (range 4-116 months). Rates of postoperative complications, including unplanned operative intervention for a reconstructive complication (2.7% versus 37.5%, p < 0.001), skin flap necrosis (10.8% versus 29.7%, p = 0.05), and infection (16.2% versus 35.9, p = 0.04) were significantly higher in the mastectomy group. Overall, 45.3% of patients who underwent mastectomy developed at least one breast complication, compared to 18.9% of patients who underwent oncoplastic mammoplasty (p = 0.01). If XRT is indicated after mastectomy, attempts should be made to achieve breast conservation through the use of neo-adjuvant therapy and oncoplastic surgery in order to optimize surgical outcomes. Breast conservation with oncoplastic reconstruction does not compromise oncologic outcome, but significantly reduces complications compared to postmastectomy reconstruction followed by XRT.

Impact of total skin-sparing mastectomy incision type on reconstructive complications following radiation therapy.

BACKGROUND: Postoperative complications after total skin-sparing mastectomy and expander-implant reconstruction can negatively impact outcomes, particularly in the setting of postmastectomy radiation therapy. The authors studied whether rates of ischemic complications after postmastectomy radiation therapy are impacted by the total skin-sparing mastectomy incision. METHODS: The authors queried a prospectively collected database of patients undergoing total skin-sparing mastectomy and immediate two-stage expander-implant reconstruction. Their hypothesis was that, in the setting of radiation therapy, patients with inframammary incisions would be more likely to develop ischemic complications than those without incisions on the dependent portion of the breast. We divided our patient cohort into two groups, those with inframammary incisions and those with other incisions, and then analyzed the proportion that received radiation therapy. RESULTS: Of 756 cases included in the analysis, 91 (12 percent) received postmastectomy radiation therapy, 62 (68.1 percent) with inframammary incisions and 29 (31.9 percent) with other incisions. Mean follow-up was 3.1 years. Rates of mastectomy skin flap necrosis (3.2 percent versus 6.9 percent, p=0.4) following radiation therapy were not significantly higher in the inframammary group. However, breakdown of the total skin-sparing mastectomy incision was twice as likely in the inframammary group (21 percent versus 10.3 percent, p=0.2) and was more likely to lead to subsequent implant removal when incisional breakdown occurred (77 percent versus 0 percent, p=0.03). CONCLUSIONS: Total skin-sparing mastectomy incision type may impact rates of incisional breakdown and implant loss following postmastectomy radiation therapy, with higher rates seen with inframammary incisions. Multiple factors, including breast size, breast ptosis, and likelihood of radiation therapy, should be considered in determining optimal incision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate implant-based breast reconstruction following total skin-sparing mastectomy in women with a history of augmentation mammaplasty: assessing the safety profile.

BACKGROUND: Preservation of the nipple-areolar complex with total skin-sparing mastectomy is becoming a popular mastectomy technique. As experience increases, the patient inclusion criteria for total skin sparing mastectomy expand. The authors assessed outcomes of total skin-sparing mastectomy and immediate prosthetic reconstruction in women with a prior history of augmentation mammaplasty. METHODS: Between 2005 and 2012, all women with a history of augmentation mammaplasty and implants in place, undergoing total skin-sparing mastectomy and immediate prosthetic reconstruction, were prospectively tracked. Patient demographics, expander coverage type, adjuvant treatment, and incidence of complications were analyzed. Outcomes in these patients were compared with those of patients undergoing the same operation, without prior augmentation history. RESULTS: Thirty-four women with prior augmentation underwent total skin-sparing mastectomy and immediate tissue expander placement on 51 breasts. Comparison to the nonaugmentation group showed similar rates of superficial nipple necrosis (0 percent, p=0.324), complete nipple necrosis (0 percent, p=0.324), and skin flap necrosis (4 percent, p=1.0). The prior augmentation group did have a higher rate of implant loss (10 percent, p=0.515), with all but one of these occurring in irradiated patients. CONCLUSIONS: Total skin-sparing mastectomy and immediate prosthetic reconstruction is a safe technique in women with a history of augmentation mammaplasty. The preferred reconstructive technique is immediate submuscular tissue expander placement. In the setting of no radiation history, this operation carries a safety profile similar to that of patients without a history of prior augmentation, and can be offered safely. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction.

BACKGROUND: Total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex skin has become more widely accepted. Few studies looking at outcomes after TSSM and immediate reconstruction have focused on patient-reported outcomes and trends in satisfaction over time. METHODS: Prospective evaluation of patients undergoing TSSM and immediate expander-implant reconstruction was performed. Patients completed the BREAST-Q questionnaire preoperatively and again at 1 month, 6 months, and 1 year postoperatively. Mean scores in each BREAST-Q domain were assessed at each time point. Domains were scored on a 0- to 100-point scale. RESULTS: Survey completion rate was 55%; BREAST-Q scores were calculated from responses from 28 patients. Mean overall satisfaction with breasts declined at 1 month (69.8 to 46.1, P<0.001), but then returned to baseline by 1 year. Mean scores also declined at 1 month in the psychosocial (75.7-67.4, P=0.2) and sexual (58.3-46.7, P=0.06) domains, but returned to baseline by 1 year. Mean nipple satisfaction score was 76.4 at 1 year, with 89% of patients reporting satisfaction with nipple appearance. Satisfaction with nipple position and sensation was lower, with only 56% of patients reporting satisfaction with nipple position and 40% with nipple sensation. CONCLUSIONS: After TSSM and immediate reconstruction, patient satisfaction with their breasts, as well as psychosocial and sexual well-being, returns to baseline by 1 year. Although overall nipple satisfaction is high, patients often report dissatisfaction with nipple position and sensation; appropriate preoperative counseling is important to set realistic expectations.

Feasibility of Performing Total Skin-Sparing Mastectomy in Patients With Prior Circumareolar Mastopexy or Reduction Mammoplasty Incisions.

INTRODUCTION: Total skin-sparing mastectomy (TSSM) techniques with preservation of the nipple-areolar complex (NAC) skin are becoming increasingly popular due to improved cosmesis without compromise in oncologic safety. However, these techniques are not routinely offered to patients who have undergone previous breast surgery involving circumareolar incisions due to concern for NAC viability. METHODS: We reviewed the outcomes of TSSM in 11 patients who underwent 21 TSSM procedures at our institution between 2008 and 2011. All patients had undergone previous breast surgery including reduction mammaplasty (7 breasts), mastopexy (4 breasts), augmentation (3 breasts), and combined mastopexy-augmentation (7 breasts). Incisions from previous breast surgery included circumareolar (11 cases) and Wise pattern (10 cases) incisions. All patients underwent TSSM through an inframammary incision followed by immediate tissue expander reconstruction and subsequent implant exchange. Patient demographics, previous breast surgery details, tumor and treatment characteristics, and postoperative complications were reviewed. RESULTS: Mean patient age was 43 years (range, 35-53 years) and mean body mass index was 24 kg/m (range, 19-32 kg/m). Mean follow-up was 10.2 months (range, 3-20 months).Indications for TSSM included prophylactic risk reduction in 10 cases, in situ cancer in 2 cases, and invasive cancer in 9 cases. Mean time from previous breast surgery to mastectomy was 6.9 years (range, 6 months-26 years). Major complications requiring operative reintervention included 1 (4.8%) case of cellulitis requiring expander removal and 2 (9.5%) cases of wound breakdown requiring operative closure. There were no complications involving the NAC. CONCLUSIONS: Total skin-sparing mastectomy with immediate reconstruction can safely be performed in patients who have undergone previous breast surgery involving circumareolar incisions. Our preferred technique in this group of patients is to perform TSSM through an inframammary incision with 2-stage expander-implant reconstruction to minimize NAC ischemia and subsequent complications.

Total skin-sparing mastectomy: a systematic review of oncologic outcomes and postoperative complications.

INTRODUCTION: Despite the potential aesthetic and psychological benefits of total skin-sparing mastectomy (TSSM) with preservation of the nipple-areolar complex (NAC) skin, there is still reluctance to use the technique due to concern for increased recurrence rates or higher postoperative complication rates. The rapidly expanding literature describing outcomes after TSSM enables a comprehensive review of recurrence rates and surgical complications. METHODS: Studies describing nipple-sparing or TSSM were identified from the MEDLINE and Cochrane databases. Studies that reported oncologic outcomes and/or data on postoperative complications were included. RESULTS: Twenty-seven studies were identified that met inclusion criteria, representing a total of 3331 mastectomies. Review of oncologic outcomes in the 10 studies (representing 1148 mastectomies) with documented mean/median follow-up of 2 years demonstrated an overall local-regional recurrence rate of 2.8%. Ischemic complications involving the NAC were reported in 24 studies (representing 3091 mastectomies), with 9.1% of cases reported to have some degree of NAC necrosis and 2.0% of cases complicated by complete necrosis leading to NAC loss. Sixteen studies (representing 2213 mastectomies) reported rates of skin flap necrosis, which occurred in 9.5% of cases. Eighty-one percent of the total cases reviewed involved expander-implant reconstruction; in the 16 studies (representing 2343 reconstructions) that reported outcomes after expander-implant reconstruction, overall expander-implant loss was 3.4%. CONCLUSIONS: There is now a significant body of literature demonstrating low rates of early local-regional recurrence and postoperative complications after TSSM. These data support the use of TSSM techniques, which improve psychological and aesthetic outcomes without compromising therapeutic efficacy.

Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure.

BACKGROUND: Increased rates of complications can occur when postmastectomy radiation therapy is required after immediate expander-implant breast reconstruction. The sequence and timing of tissue expansion and implant exchange with regard to postmastectomy radiation therapy may impact complication rates. METHODS: A prospectively maintained database of patients undergoing mastectomy and immediate reconstruction was queried for patients who underwent postmastectomy radiation therapy. The authors' protocol is to complete tissue expansion before radiation, irradiate the fully inflated expander, and then perform expander-implant exchange. Starting in 2009, the authors refined their protocol by increasing the time interval between completion of radiation therapy and expander-implant exchange from 3 months to 6 months as a strategy to reduce surgical complications. For analysis, patients were divided into two cohorts based on whether expander-implant exchange was performed less than 6 months or more than 6 months after radiation. The primary outcome was expander-implant failure, defined as device removal without concurrent replacement. RESULTS: Eighty-eight patients met selection criteria; 49 (55.7 percent) had expander-implant exchange within 6 months of completing radiation therapy (mean, 3.4 months; range, 1.2 to 5.8 months), and the rest had at least a 6-month interval (mean, 8.6 months; range, 6.1 to 17.1 months). Risk factors for postoperative complications were equivalent between cohorts. Overall expander-implant failure was 15.9 percent; failure was significantly higher in the cohort with less than 6 months' time before exchange (22.4 percent versus 7.7 percent, p = 0.036). CONCLUSION: Delaying expander-implant exchange for at least 6 months after the completion of postmastectomy radiation therapy can significantly reduce expander-implant failure.

The effects of acellular dermal matrix in expander-implant breast reconstruction after total skin-sparing mastectomy: results of a prospective practice improvement study.

BACKGROUND: Neither outcome after total skin-sparing mastectomy and expander-implant reconstruction using acellular dermal matrix nor a strategy for optimal acellular dermal matrix selection criteria has been well described. METHODS: Prospective review of three patient cohorts undergoing total skin-sparing mastectomy with preservation of the nipple-areola complex and immediate expander-implant reconstruction from 2006 to 2010 was performed. Cohort 1 (no acellular dermal matrix) comprised 90 cases in which acellular dermal matrix was not used. Cohort 2 (consecutive acellular dermal matrix) included the next 100 consecutive cases, which all received acellular dermal matrix. Cohort 3 (selective acellular dermal matrix) consisted of the next 260 cases, in which acellular dermal matrix was selectively used based on mastectomy skin flap thickness. Complication rates were compared using chi-square analysis. RESULTS: The study included 450 cases in 288 patients. Mean follow-up was 25.5 months. Infection occurred in 27.8 percent of the no-acellular dermal matrix cases, 20 percent of the consecutive cases, and 15.8 percent of the selective cases (p = 0.04). Unplanned return to the operating room was required in 23.3, 11, and 10 percent of cases, respectively (p = 0.004). Expander-implant loss occurred in 17.8, 7, and 5 percent of cases, respectively (p = 0.001). Additional analysis of the odds ratios of developing complications after postmastectomy radiation therapy demonstrated a specific protective benefit of acellular dermal matrix in irradiated patients. CONCLUSIONS: Acellular dermal matrix use in expander-implant reconstruction after total skin-sparing mastectomy reduced major postoperative complications in this study. Maximal benefit is achieved with selected use in patients with thin mastectomy skin flaps and those receiving radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.