Hannah Headon

The Oncological Safety of Nipple-Sparing Mastectomy: A Systematic Review of the Literature with a Pooled Analysis of 12,358 Procedures

Nipple-sparing mastectomy (NSM) is increasingly popular as a procedure for the treatment of breast cancer and as a prophylactic procedure for those at high risk of developing the disease. However, it remains a controversial option due to questions regarding its oncological safety and concerns regarding locoregional recurrence. This systematic review with a pooled analysis examines the current literature regarding NSM, including locoregional recurrence and complication rates. Systematic electronic searches were conducted using the PubMed database and the Ovid database for studies reporting the indications for NSM and the subsequent outcomes. Studies between January 1970 and January 2015 (inclusive) were analysed if they met the inclusion criteria. Pooled descriptive statistics were performed. Seventy-three studies that met the inclusion criteria were included in the analysis, yielding 12,358 procedures. After a mean follow up of 38 months (range, 7.4–156 months), the overall pooled locoregional recurrence rate was 2.38%, the overall complication rate was 22.3%, and the overall incidence of nipple necrosis, either partial or total, was 5.9%. Significant heterogeneity was found among the published studies and patient selection was affected by tumour characteristics. We concluded that NSM appears to be an oncologically safe option for appropriately selected patients, with low rates of locoregional recurrence. For NSM to be performed, tumours should be peripherally located, smaller than 5 cm in diameter, located more than 2 cm away from the nipple margin, and human epidermal growth factor 2-negative. A separate histopathological examination of the subareolar tissue and exclusion of malignancy at this site is essential for safe oncological practice. Long-term follow-up studies and prospective cohort studies are required in order to determine the best reconstructive methods.

Breast Lipofilling: A Review of Current Practice

Lipofilling is a reconstructive and aesthetic technique that has recently grown in popularity and is increasingly being used in breast surgery. Previous concerns had been raised regarding its safety when used for remodelling and reconstruction of the breast; however, these concerns have since been dismissed. Over the subsequent two decades, little evidence has been found to support these early theoretical concerns, and growing numbers of proponents of the procedure are confident in its safety. Many developments and refinements in the technique have taken place in recent years, and several studies have been published regarding the safety of lipofilling in the breast. We reviewed the current literature regarding the use of different lipofilling techniques as well as the current evidence regarding the oncological safety of the procedure in patients seeking aesthetic breast enhancement and in patients requiring reconstruction after treatment for breast cancer.

Porcine acellular dermis-based breast reconstruction: complications and outcomes following adjuvant radiotherapy

Sir, We read the study by Ng and colleagues [1] with great interest. In their study, the authors report on the use of an acellular dermal matrix (ADM, StratticeTM, LifeCell, NJ, USA) in the setting of breast reconstruction and radiotherapy treatment. In their study, Ng and colleagues describe an overall complication rate of 32 % with no significant difference between those treated with radiotherapy before surgery and those treated postoperatively. They therefore conclude that implant-based reconstruction using StratticeTM should not be an absolute contraindication in preor post-radiotherapy patients, but that the increased risks are emphasised to patients in order to better manage patient expectations if complications arise. With up to one third of women opting for mastectomy [2], the use of ADMs in breast reconstruction is becoming increasingly popular, being described as the most significant innovation impacting prosthetic breast reconstruction in recent years [3]. We recently undertook a similar study, looking at the use of a bovine-derived ADM, SurgiMendTM (TEI Biosciences, MA, USA), in a prospective case series of 118 patients undergoing 164 skin sparing mastectomy and immediate reconstruction procedures. Thirty-two patients (27 %) in our series underwent radiotherapy, of whom 27 received postmastectomy radiotherapy and 5 received it prior to surgery. Fifty-two percent of the patients received chemotherapy. Despite this relatively high uptake rate of chemotherapy and radiotherapy, we found a relatively low complication rate. At a mean follow-up of 21 months, the explantation rate was 1.2 %, and 4 % of patients developed wound complications. This included one case of partial wound dehiscence requiring surgical debridement and implant replacement in a patient who had undergone both postmastectomy radiotherapy and chemotherapy. Another patient who also received radiotherapy prior to surgery developed capsular contracture after 2 years which required capsulotomy and fat transfer. Those who lost their implants were undergoing adjuvent chemotherapy. We also found that there was high patient satisfaction with the outcome of the procedure (9 out of 10). We therefore agree with the conclusions reached by Ng and colleagues: ADM-assisted breast reconstruction should not be an absolute contraindication in patients receiving radiotherapy. The difference between results may be explained by differences in surgical technique or the different ADMs used in each of the studies, as follow-up times were similar. Furthermore, other factors have been reported to affect complication rate, such as body mass and comorbidity status; therefore, patient selection may also play a role. As Ng rightly point out, it is important to ensure that patients have adequate * Kefah Mokbel kefahmokbel@hotmail.com