Jordan D. Frey

Nipple-sparing mastectomy in patients with prior breast irradiation: are patients at higher risk for reconstructive complications?

Background: Reconstruction in the setting of prior breast irradiation is conventionally considered a higher-risk procedure. Limited data exist regarding nipple-sparing mastectomy in irradiated breasts, a higher-risk procedure in higher-risk patients. Methods: The authors identified and reviewed the records of 501 nipple-sparing mastectomy breasts at their institution from 2006 to 2013. Results: Of 501 nipple-sparing mastectomy breasts, 26 were irradiated. The average time between radiation and mastectomy was 12 years. Reconstruction methods in the 26 breasts included tissue expander (n = 14), microvascular free flap (n = 8), direct implant (n = 2), latissimus dorsi flap with implant (n = 1), and rotational perforator flap (n = 1). Rate of return to the operating room for mastectomy flap necrosis was 11.5 percent (three of 26). Nipple-areola complex complications included one complete necrosis (3.8 percent) and one partial necrosis (3.8 percent). Complications were compared between this subset of previously irradiated patients and the larger nipple-sparing mastectomy cohort. There was no significant difference in body mass index, but the irradiated group was significantly older (51 years versus 47.2 years; p = 0.05). There was no statistically significant difference with regard to mastectomy flap necrosis (p = 0.46), partial nipple-areola complex necrosis (p = 1.00), complete nipple-areola complex necrosis (p = 0.47), implant explantation (p = 0.06), hematoma (p = 1.00), seroma (p = 1.00), or capsular contracture (p = 1.00). Conclusion: In the largest study to date of nipple-sparing mastectomy in irradiated breasts, the authors demonstrate that implant-based and autologous reconstruction can be performed with complications comparable to those of the rest of their nipple-sparing mastectomy patients.

Nipple-sparing Mastectomy and Sub-areolar Biopsy: To Freeze or not to Freeze? Evaluating the Role of Sub-areolar Intraoperative Frozen Section.

Use of nipple‐sparing mastectomy (NSM) for risk‐reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple‐areolar complex remains controversial. Records of patients undergoing NSM at our institution from 2006 to 2013 were reviewed. Records from 501 nipple‐sparing mastectomies were reviewed (216 therapeutic, 285 prophylactic). Of the 480 breasts with sub‐areolar biopsies, 307 had intraoperative frozen sections and 173 were evaluated with permanent paraffin section only. Among the 307 intraoperative frozen sections, 12 biopsies were positive on permanent paraffin section (3.9% or 12/307). Of the 12 positive permanent biopsies, five were false negative and the remaining seven concordant intraoperatively. Sensitivity and specificity of sub‐areolar frozen section were 0.58 and 1, respectively. Positive sub‐areolar biopsies consisted primarily of ductal carcinoma in situ (62% or 13/21). The nipples or nipple‐areolar complex were resected in a separate procedure following mastectomy (10/21), intraoperatively following frozen section results (7/21) or during second‐stage breast reconstruction (3/21; 1 additional scheduled). Only 30% (6/20) of resected specimens had abnormal residual pathology. Intraoperative frozen section is highly specific and moderately sensitive for the detection of positive sub‐areolar biopsies in NSM. Its use can help guide intraoperative reconstructive planning. The presence of positive sub‐areolar biopsies in both contralateral and high‐risk prophylactic mastectomy specimens emphasizes the need to perform sub‐areolar biopsies in all nipple‐sparing mastectomies.

Oncologic outcomes after nipple-sparing mastectomy: A single-institution experience

Long‐term oncologic outcomes in nipple‐sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin‐sparing mastectomy (SSM) and NSM in the literature range from 0% to 14.3%. We investigated the outcomes of NSM at our institution.

Breast in a Day: Examining Single-Stage Immediate, Permanent Implant Reconstruction in Nipple-Sparing Mastectomy.

Background: Nipple-sparing mastectomy with immediate, permanent implant reconstruction offers patients a prosthetic “breast in a day” compared to tissue expander techniques requiring multiple procedures. Methods: Patients undergoing nipple-sparing mastectomy with immediate, permanent implant reconstruction were reviewed with patient demographics and outcomes analyzed. Results: Of 842 nipple-sparing mastectomies from 2006 to June of 2015, 160 (19.0 percent) underwent immediate, permanent implant reconstruction. The average age and body mass index were 46.5 years and 23.3 kg/m2. The majority of implants were either Allergan Style 20 (48.1 percent) or Style 15 (22.5 percent). The average implant size was 376.2 ml, and 91.3 percent of reconstructions used acellular dermal matrix. The average number of reconstructive operations was 1.3. Follow-up was 21.9 months. The most common major complication was major mastectomy flap necrosis (8.1 percent). The rate of reconstructive failure was 5.6 percent and implant loss was 4.4 percent. The most common minor complication was minor mastectomy flap necrosis (14.4 percent). The rates of full-thickness and partial-thickness nipple necrosis were 4.4 and 7.5 percent, respectively. Age older than 50 years (p = 0.0276) and implant size greater than 400 ml (p = 0.0467) emerged as independent predictors of overall complications. Obesity (p = 0.4073), tobacco use (p = 0.2749), prior radiation therapy (p = 0.4613), and acellular dermal matrix (p = 0.5305) were not associated with greater complication rates. Conclusion: Immediate, permanent implant reconstruction in nipple-sparing mastectomy provides patients with a breast in a day in less than two procedures, with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review

Background: The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes. Methods: A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes. Results: Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%. Conclusions: Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.

Evolution of abdominal wall reconstruction: development of a unified algorithm with improved outcomes.

IntroductionVentral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair. MethodsOne hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence. ResultsSeventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001). ConclusionsSimplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.

A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the “ideal” Neophallus an Achievable Goal?

Introduction: The complex anatomy and function of the native penis is difficult to surgically replicate. Metoidioplasty and radial forearm flap phalloplasty (RFFP) are the 2 most commonly utilized procedures for transgender neophallus construction. Methods: A MEDLINE search for metoidioplasty and RFFP in female-to-male genital reconstruction was performed. Primary outcome measures were subsequently compared. A systematic review was planned in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the quality of evidence. Results: Using Population, Intervention, Comparison and Outcomes tool criteria, a total of 188 articles were identified; 7 articles related to metoidioplasty and 11 articles related to RFFP met inclusion criteria. The GRADE quality of evidence was low to very low for all included studies. In studies examining metoidioplasty, the average study size and length of follow-up were 54 patients and 4.6 years, respectively (1 study did not report [NR]). Eighty-eight percent underwent a single-stage reconstruction (0 NR), 87% reported an aesthetic neophallus (3 NR), and 100% reported erogenous sensation (2 NR). Fifty-one percent of patients reported successful intercourse (3 NR), and 89% of patients achieved standing micturition (3 NR). In studies examining RFFP, the average study size and follow-up were 60.4 patients and 6.23 years, respectively (6 NR). No patients underwent single-stage reconstructions (8 NR). Seventy percent of patients reported a satisfactorily aesthetic neophallus (4 NR), and 69% reported erogenous sensation (6 NR). Forty-three percent reported successful penetration of partner during intercourse (6 NR), and 89% achieved standing micturition (6 NR). Compared with RFFP, metoidioplasty was significantly more likely to be completed in a single stage (P < 0.0001), have an aesthetic result (P = 0.0002), maintain erogenous sensation (P < 0.0001), achieve standing micturition (P = 0.001), and have a lower overall complication rate (P = 0.02). Conclusions: Although the current literature suggests that metoidioplasty is more likely to yield an “ideal” neophallus compared with RFFP, any conclusion is severely limited by the low quality of available evidence.

Breast Reconstruction Using Contour Fenestrated AlloDerm: Does Improvement in Design Translate to Improved Outcomes?

Background: Acellular dermal matrices are used in implant-based breast reconstruction. The introduction of contour fenestrated AlloDerm (Life-Cell, Branchburg, N.J.) offers sterile processing, a crescent shape, and prefabricated fenestrations. However, any evidence comparing reconstructive outcomes between this newer generation acellular dermal matrices and earlier versions is lacking. Methods: Patients undergoing implant-based breast reconstruction from 2010 to 2014 were identified. Reconstructive outcomes were stratified by 4 types of implant coverage: aseptic AlloDerm, sterile “ready-to-use” AlloDerm, contour fenestrated AlloDerm, or total submuscular coverage. Outcomes were compared with significance set at P < 0.05. Results: A total of 620 patients (1019 reconstructions) underwent immediate, implant-based breast reconstruction; patients with contour fenestrated AlloDerm were more likely to have nipple-sparing mastectomy (P = 0.0001, 0.0004, and 0.0001) and immediate permanent implant reconstructions (P = 0.0001). Those with contour fenestrated AlloDerm coverage had lower infection rates requiring oral (P = 0.0016) and intravenous antibiotics (P = 0.0012) compared with aseptic AlloDerm coverage. Compared with sterile “ready-to-use” AlloDerm coverage, those with contour fenestrated AlloDerm had similar infection outcomes but significantly more minor mastectomy flap necrosis (P = 0.0023). Compared with total submuscular coverage, those with contour fenestrated AlloDerm coverage had similar infection outcomes but significantly more explantations (P = 0.0001), major (P = 0.0130) and minor mastectomy flap necrosis (P = 0.0001). Significant independent risk factors for increased infection were also identified. Conclusions: Contour fenestrated AlloDerm reduces infections compared with aseptic AlloDerm, but infection rates are similar to those of sterile, ready-to-use AlloDerm and total submuscular coverage.

Reconstructive Approach for Patients With Augmentation Mammaplasty Undergoing Nipple-Sparing Mastectomy

BACKGROUND Nipple-sparing mastectomy (NSM) is a recent advance in the therapeutic and prophylactic management of breast cancer; however, the procedure is associated with increased reconstructive complications. Data on NSM after previous breast augmentation are limited. OBJECTIVES The authors compared reconstructive complications after NSM between patients with previously augmented breasts and a larger cohort that had not undergone prior augmentation. An approach to NSM that involves 2-stage reconstruction in augmented patients is also described. METHODS Medical records of NSMs performed at New York University Langone Medical Center from 2006 to 2013 were reviewed. Data points evaluated included patient characteristics, comorbidities, breast implant plane, and reconstructive complications. Fishers exact and t tests were used for the comparisons. RESULTS During the study period, NSMs were performed in 17 augmented breasts at this institution. After NSM, 15 of these breasts underwent implant-based reconstruction and 2 breasts underwent microvascular free flaps. Reconstructive complications included 1 hematoma managed nonoperatively (5.9%) and 1 partial necrosis of the nipple-areola complex (NAC) (5.9%). Compared with the larger nonaugmented cohort (n=332), patients with previously augmented breasts had fewer complications, and there were no statistically significant differences in the rates of mastectomy flap necrosis, partial NAC necrosis, complete NAC necrosis, hematoma, capsular contracture, explantation, implant displacement, seroma, or breast cellulitis. CONCLUSIONS The results indicate that NSM reconstruction is associated with minimal complications in patients with previous augmentation mammaplasty. LEVEL OF EVIDENCE 4.

Angiosarcoma of the Breast Masquerading as Hemangioma: Exploring Clinical and Pathological Diagnostic Challenges

Vascular tumors of the breast are very rare. Angiosarcomas account for only 0.04% of all breast tumors and 3% to 9% of breast sarcomas and may be primary or, more commonly, secondary [1,2,3,4,5]. Primary angiosarcomas of the breast require a high degree of clinical suspicion for accurate diagnosis and appropriate treatment. Even so, they may be misdiagnosed and treatment must be thoughtfully directed with this possibility in mind. We present a case report illustrating the challenges to accurate and timely diagnosis of primary angiosarcoma of the breast despite thorough preoperative work-up. The patient is a 44-year-old nulliparous woman with no significant past medical or surgical history. Her most recent mammogram demonstrated only bilateral fibrocystic disease. She presented to one of the authors with a two month history of a rapidly enlarging right breast; most notably with deformation and fullness of the superior pole. An ultrasound performed in the office revealed a 15-cm lesion of the right breast and subsequent fine-needle aspiration (FNA) was performed. The aspiration biopsy showed dissociated and clustered bland spindle cells. Some tumor cells exhibited mild cytologic atypia with intracytoplasmic metachromatic material which may represent degenerated red blood cells, and nuclear membrane irregularities (Figs. 1, ​,2).2). The diagnosis was that of a spindle cell lesion. Fig. 1 Aspiration biopsy (Diff Quik stain, ×20). Cluster of mildly pleomorphic spindle cells in a background of blood. Fig. 2 Aspiration biopsy (Diff Quik stain, ×40). Microacinar groups of spindle and epithelioid cells associated with scant intracytoplasmic metachromatic material. A subsequent core biopsy showed areas of vascular proliferation with individual channels isolated from one another; there were also areas of anastomosing vascular spaces lined by mildly pleomorphic endothelial cells with rare mitotic figures (Fig. 3). A diagnosis of hemangioma was made. Fig. 3 Core biopsy (H&E, ×20). Anastomosing vascular channels lined by bland spindle cells. A magnetic resonance imaging (MRI) confirmed a 6.6×6.3×7.4 cm enhancing heterogeneous, hyperintense mass on T1- and T2-weighted images in the right breast with superficial feeding vessels and skin contact without intramuscular extension (Fig. 4). The following day, she underwent right partial mastectomy with excision of the mass with a margin of surrounding breast tissue. A partial mastectomy was performed in place of simple excision of the presumed hemangioma due to the size of the lesion and the possibility of malignancy despite imaging and biopsies suggesting otherwise. Intraoperatively, the mass was noted to be heterogeneously solid and cystic. A lymph node in the tail of Spence was biopsied. A large defect was created by the resection requiring mobilization of a medial pillar of breast tissue to fill the defect with good cosmetic outcome. Fig. 4 Axial post-contrast magnetic resonance imaging of right breast lesion. Final pathology revealed an ill-defined infiltrative 9.0 cm tumor composed of inter-anastomosing channels and blood lakes lined by atypical cells including focal hobnail cells. There were multiple solid areas of tumor demonstrating a high mitotic rate (up to 25/mm2). No tumor necrosis was identified. Immunostains for CD31, CD34, and ERG highlighted the tumor cells in the solid areas as well as the cells lining the interanastomosing channels confirming the endothelial differentiation of the tumor. Overall, the findings were diagnostic of angiosarcoma, grade 3. Anterior, superior and inferior margins were positive for malignancy. The lymph node was negative for sarcoma. This case is unique for a variety of reasons. While the size and growth of the mass presented was more consistent with angiosarcoma than hemangioma, clinical evaluation is non-specific. Often, patients have only a painless mass with a bluish hue only as in this case [1], leaving physicians to rely on radiological and pathological data for diagnosis prior to definitive excision. This patients initial diagnosis of benign hemangioma was predicated on multiple imaging and tissue studies. When found on mammography, angiosarcomas present as poorly defined masses without calcifications with 19% to 33% being mammographically occult [1], as in the patients case. Ultrasound findings in breast hemangiomas demonstrate heterogeneous echogenecity without acoustic shadowing [1]. While the patients ultrasound imaging demonstrated mixed echogenicity with both peripheral and central vascularity, acoustic shadowing was present and the vascularity was not uniform throughout the lesion. An MRI was obtained to better delineate the lesions extension within the breast. MRI typically demonstrates a hypointense lesion on T1-weighted images and a hyper-intense lesion on T2-weighted images [5]. The patients MRI results, however, demonstarted hyperintense lesions on T1- and T2-weighted images without extension into the pectoralis fascia. FNA results of vascular tumors of the breast are largely indeterminate and may show hypocellularity; however, it is often not adequate to differentiate malignant from benign vascular tumors. The patients FNA showed an indeterminate spindle cell lesion. CNB is favored in the diagnosis of breast vascular tumors as it is touted to definitively differentiate benign and malignant lesions. Despite an adequate sample, CNB incorrectly identified the lesion as capillary hemangioma. Cellular markers of angiosarcoma are not useful since they simply demonstrate the endothelial (vascular) nature of the lesion; a feature both lesions share (personal communication). As illustrated in this case, the diagnosis of angiosarcoma requires a high degree of clinical suspicion and is very difficult to differentiate from benign hemangiomas [1], a capillary hemangioma in this case. Both confirmatory imaging and tissue studies contributed to the misdiagnosis on initial presentation. The treatment of benign hemangiomas of the breast is simple excision whereas treatment of angiosarcoma requires complete local excision with margins or total mastectomy [1]. Mixed results have suggested that radical surgical intervention does not offer a significant survival advantage compared to conservative treatment. Despite the tissue diagnosis of a benign lesion, the mass was removed with a cuff of normal breast parenchyma with intent to remove all visible tumor with margins given its large size. While the role of adjuvant chemoradiation in the treatment of angiosarcoma of the breast remains controversial, she has elected for conservative expectant management and will forego adjuvant therapy at this time. We present the case of a 44-year-old woman with a rapidly enlarging unilateral breast mass initially diagnosed through imaging and tissue biopsy as a capillary hemangioma, but found to be grade III primary angiosarcoma on surgical excision. This case illustrates the importance of clinical suspicion in vascular tumors of the breast as imaging and tissue studies may be indeterminate and misleading. When clinical suspicion remains high despite biopsy results, complete excision with margins or mastectomy should be undertaken while awaiting final pathology.