Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery.

BACKGROUND: Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS. MATERIALS AND METHODS: Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss. RESULTS: 956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567). CONCLUSION: In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Breast-Specific Sensuality and Appearance Satisfaction: Comparison of Breast-Conserving Surgery and Nipple-Sparing Mastectomy.

BACKGROUND: We demonstrated previously that lumpectomy (L) patients reported higher appearance satisfaction, appreciation of a pleasurable breast caress, and persistence of the breast during intimacy than mastectomy with reconstruction, which we used to describe breast-specific sensuality. Our current objective was to compare breast-specific sensuality between L and nipple-sparing mastectomy (NSM). DESIGN: An anonymous, cross-sectional survey was distributed to breast cancer survivors between 2014 and 2016. Eligible patients underwent operation between 2000 and 2014, were adults older than 18 years, English-speaking, and at least one year into the post-operative period. Demographic characteristics, treatment details, Female Sexual Function Index metrics, and investigator-generated questions about appearance satisfaction and breast-specific sensuality were collected. RESULTS: Of the 600 women who participated, 585 surveys were eligible. Surgical modality was reported as L by 406 (69.4%), mastectomy alone by 50 (8.5%), and mastectomy with reconstruction by 129 (22.1%). Nipple-preservation data were available for 47 of 129 mastectomy with reconstruction patients (36.4%), with 21 NSM and 26 non-nipple-sparing mastectomy patients. Favorable postoperative appearance satisfaction was reported by 76.2% of L and 71.4% of NSM (p = 0.039). Lumpectomy patients reported feeling more comfortable being seen undressed than NSM patients (82.4% vs 71.4%; p = 0.0003). The chest remained a part of intimacy for 65.4% of L patients vs 42.9% of NSM patients (p = 0.0009). A pleasurable breast caress was reported more frequently by L patients than NSM patients (66.2% vs 20%; p ≤ 0.0001). The breast caress was unpleasant for 40% of NSM patients, nearly 4-fold higher than L patients (11.3%; p < 0.0001). CONCLUSIONS: NSM patients were significantly less satisfied with appearance, less comfortable being seen undressed, had decreased persistence of breast intimacy, and experienced a less pleasurable breast caress than L patients. Counseling patients about these findings will empower informed decision making, optimize expectations, and can enhance postoperative satisfaction.

Quality of life and sexual well-being after nipple sparing mastectomy: A matched comparison of patients using the breast Q.

BACKGROUND: Nipple sparing mastectomy (NSM) is considered safe for select patients. Our objective was to examine quality of life (QOL) and satisfaction for NSM compared with skin sparing mastectomy (SSM). We aimed to evaluate these using the BREAST-Q. METHODS: After IRB approval, we analyzed patients who underwent NSM and reconstruction between July 2010-June 2015. NSM patients were matched with those after SSM based on age, race, and body mass index. Telephone interviews were prospectively conducted using the BREAST-Q Mastectomy Postoperative Module. Bivariate analysis and a paired samples t-test were performed. RESULTS: We identified 43 patients meeting our inclusion criteria with a response rate 60% (N = 26). NSM and SSM patients were matched well in age (P = 1.00), race (P = 1.00), and Body Mass Index (P = 0.99). There were no significant differences in stage, estrogen and progesterone status, HER2 expression, reconstruction type and radiation. Mean BREAST-Q scores did not vary between NSM and SSM in regards to satisfaction with breasts (P = 0.604), psychosocial well-being (P = 0.146), physical well-being (P = 0.121), and satisfaction with surgeon (P = 0.170). Sexual well-being was significantly higher in NSM patients (P = 0.011). CONCLUSION: NSM provides patients with favorable results in psychosocial, sexual, and physical well-being and overall satisfaction. Sexual well-being showed significant improvement for NSM.

Subcutaneous Mastectomy Improves Satisfaction with Body and Psychosocial Function in Trans Men: Findings of a Cross-Sectional Study Using the BODY-Q Chest Module.

BACKGROUND: The effectiveness of gender-confirming surgery is best evaluated on the basis of patient-reported outcomes. This is the first explorative study using the BODY-Q chest module, administered in trans men before and after mastectomy. METHODS: Between October of 2016 and May of 2017, trans men were recruited to participate in a cross-sectional study. Data collection included standardized anamnesis and examination, screening questions on depression/anxiety, and seven BODY-Q scales, including new scales measuring satisfaction of the chest and nipples. Mean scores for preoperative and postoperative participants were compared, and regression analyses were conducted to identify factors associated with BODY-Q scores. RESULTS: In total, 101 persons participated (89 percent; 50 preoperatively and 51 postoperatively). Postoperative participants reported significantly higher (better) scores on the chest (67), nipple (58), body (58) (t tests, all p < 0.001), and psychological (60) (t test, p = 0.05) scales compared with preoperative patients. Postoperative chest and nipple mean scores did not differ significantly from a gynecomastia comparison, whereas scores were less favorable on the psychosocial domains. Preoperatively, chest scores were not associated with objective breast size. Lower postoperative chest scores were associated with planned revision surgery (ß = -0.52) and depressive symptoms (ß = -0.59). CONCLUSIONS: The present findings indicate that chest and nipple satisfaction differences in trans men undergoing mastectomy can be detected using the BODY-Q chest module. Future prospective studies are needed to measure clinical change in satisfaction and how this relates to changes in other aspects of health-related quality of life.

Psychosocial and Sexual Well-Being Following Nipple-Sparing Mastectomy and Reconstruction.

Nipple-sparing mastectomy (NSM) is considered an oncologically safe option for select patients. As many patients are candidates for nipple-sparing or skin-sparing mastectomy (SSM), reliable patient-reported outcome data are crucial for decision-making. The objective of this study was to determine whether patient satisfaction and/or health-related quality of life (HRQOL) were improved by preservation of the nipple with NSM compared to SSM and nipple reconstruction. Subjects were identified from a prospectively maintained database of patients who completed the BREAST-Q following mastectomy and breast reconstruction between March and October 2011 at Memorial Sloan Kettering Cancer Center. Fifty-two patients underwent NSM followed by immediate expander-implant reconstruction. A comparison group consisted of 202 patients who underwent SSM followed by immediate expander-implant reconstruction and later nipple reconstruction. HRQOL and satisfaction domains as measured by BREAST-Q scores were compared in multivariate linear regression analyzes that controlled for potential confounding factors. NSM patients reported significantly higher scores in the psychosocial (p = 0.01) and sexual well-being (p = 0.02) domains compared to SSM patients. There was no significant difference in the BREAST-Q physical well-being, satisfaction with breast, or satisfaction with outcome domains between the NSM and SSM groups. NSM is associated with higher psychosocial and sexual well-being compared to SSM and nipple reconstruction. Preoperative discussion of such HRQOL outcomes with patients may facilitate informed decision-making and realistic postoperative expectations.

Nipple-sparing mastectomy in modern breast practice.

Breast cancer management has evolved from the conventional radical Halsted to a fully integrated multidisciplinary approach. Nipple sparing mastectomy (NSM) is an innovative technique that preserves native breast envelope without mutilation of nipple-areola complex (NAC), thus providing a reasonable alternative for early cancers without NAC involvement and prophylactic high risk patients and avoids multiple surgical procedures required for reconstruction. This article aims to critically review indications, intra-operative protocols, radiotherapy planning and limitations of NSM. Patient selection should be based on study of breast duct anatomy by Magnetic Resonance Imaging, mammographic tumor-nipple distance and obligatory intra-operative frozen section from retro-areolar tissue. Tumor size, axillary lymph node status, lymphovascular invasion and/or degree of intraductal component are factors used to include NSM candidates based on institutional practice. Given the heterogeneity of patients and lack of standardization of preoperative investigations, surgical technique and pathologic sampling of retro-areola tissue so far, mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis is an important NSM complication which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.

Conservative mastectomy: extending the idea of breast conservation.

Conservative mastectomy is a surgical technique to remove breast glandular tissue without disruption to the appearance of the breast. The main contraindication to this operation is involvement of the nipple-areola complex. Preservation of a healthy nipple does not affect long-term survival rates. Intraoperative retroareolar biopsy and accurate removal of all mammary tissue are mainstays to guarantee oncological safety of the technique. A complication, however infrequent, is nipple necrosis, which can be treated successfully by local excision. Several breast reconstructive techniques are used during conservative mastectomy and aesthetic results are good in most cases.

Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study.

Prophylactic bilateral mastectomy is an option for women who are at an increased risk of developing breast cancer. Prophylactic mastectomy is often performed with immediate reconstruction (i.e., at the same time and under the same anesthetic as the mastectomy). Satisfaction with reconstruction has been described previously for women with mastectomy for breast cancer. However, the authors know of no previous research that has reported on satisfaction with reconstruction in patients who have electively sought mastectomy for the prevention of breast cancer. Women in the province of Ontario who had undergone prophylactic bilateral mastectomy plus breast reconstruction between 1991 and 2000 were asked to rate their level of satisfaction with the cosmetic results of their mastectomy and reconstruction and their overall satisfaction with their decision to have prophylactic mastectomy. Women were also asked whether they experienced complications associated with their surgery and what types of complications they experienced. Thirty-seven women completed questionnaires for this study, and all of them had immediate breast reconstruction after prophylactic mastectomy. The majority of women (70.3 percent) reported being satisfied or extremely satisfied with the cosmetic results of their breast reconstruction. Women with self-reported postsurgical complications (16.2 percent) were significantly less satisfied with reconstruction than those who did not report complications (p = 0.009). Personal subjective risk of breast cancer before prophylactic mastectomy was negatively correlated with satisfaction with reconstruction (r = -0.38, p = 0.024) and with subjective risk estimation after prophylactic surgery (r = -0.54, p = 0.001). Women who did not worry about developing breast cancer after prophylactic mastectomy had significantly higher levels of satisfaction with breast reconstruction than those who continued to worry (p < 0.001). Women who reported an improved body image after reconstruction were significantly more likely to report higher levels of satisfaction than those who reported a diminished body image (p = 0.007). The majority of women were satisfied with the cosmetic results of breast reconstruction after prophylactic mastectomy. Women who overestimated their breast cancer risk had lower satisfaction levels. Correcting overestimation of breast cancer risk in women who have prophylactic mastectomy may improve satisfaction with reconstruction following prophylactic mastectomy.

The psychological impact of immediate rather than delayed breast reconstruction.

AIMS: A retrospective analysis of the psychological advantages of immediate reconstruction (IR) against delayed reconstruction (DR). METHODS: A total of 121 patients who underwent different types of breast reconstruction were seen in the follow-up clinic and assessed for: anxiety, depression, body image, self-esteem, sexuality and satisfaction. RESULTS: Ninety-five percent of the patients who had IR preferred this technique and 76% of the DR group would have preferred IR. Anxiety and depression were decreased and body image, self-esteem and sexual feeling of attractiveness and satisfaction were significantly superior in the IR group compared with that of the DR group. CONCLUSION: Patients who had immediate reconstruction recalled less distress and had better psychosocial well being than those who had delayed reconstruction.

Prophylactic mastectomy for genetic predisposition to breast cancer: the proband's story.

The identification of the BRCA1 gene may prove a mixed blessing in the short term. First, the demand for testing might outstrip available resources, the ethics of testing are complex and the advice to give someone who tests positive is as yet unclear. Furthermore, the psychological dynamics within such families have not yet been considered seriously. As these families might be widespread, there will inevitably be problems involving clinical genetic centres in different parts of the country, or for that matter, in different areas of the world. In this paper we provide a case report, which might be considered an adumbration of things to come. The proband in this story (a co-author) was known to have inherited a genetic predisposition to cancer. This was because her identical twin had already developed the disease and she came from a kindred with a very high probability for carrying a dominant breast cancer gene in the germ line. We describe the personal reactions of an individual woman faced with these difficult decisions, the impact on her family and the impact on the clinical genetic services in different parts of the country. Our experience could help to provide a template for the development of regional services once genetic testing for predisposition to breast cancer becomes widely available.

[Psychosocial aspects of bilateral subcutaneous reduction mastectomy in breast cancer]. / Psychosoziale Aspekte der beidseitigen subkutanen Reduktionsmastektomie bei Mammakarzinom.

The authors administered a questionnaire to 56 women with breast cancer who had bilateral subcutaneous mastectomies after Stroembeck/Beller since 1985. In this study, psychological aspects were investigated. There was no change in social behavior; isolation was not noticed. The negative effects on the body image were well accepted and discussed with relatives and friends. Psychological or emotional suffering was rare compared to patients with simple mastectomy. No change in sexual behavior was reported. The sexual function of the mamillae was significantly reduced. Although some cosmetic deformities were obvious, most patients would again choose the subcutaneous reduction mastectomy as operation of choice.