Michael Alperovich

Nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy: how safe is it?

Background: Nipple-sparing mastectomy has gained popularity, but the question remains of whether it can be offered safely to women with a history of reduction mammaplasty or mastopexy. The authors present their experience with nipple-sparing mastectomy in this patient population. Methods: Patients at the authors’ institution who had reduction mammaplasty or mastopexy before nipple-sparing mastectomy were identified. Outcomes measured include nipple-areola complex viability, mastectomy flap necrosis, infection, presence of cancer in the nipple-areola complex, and breast cancer recurrence. Results: The records of the nipple-sparing mastectomy patients at the authors’ institution from 2006 through 2012 were reviewed. The authors identified 13 breasts in eight patients that had nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Within this subset of patients, the mean age was 46.6 years and the mean body mass index was 25.1. Nine of 13 breasts had therapeutic resections, whereas the remaining four were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 51.8 months (range, 33 days to 11 years). In all cases, prior reduction mammaplasty/mastopexy incisions were used for nipple-sparing mastectomy. Ten breasts underwent reconstruction immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and two with immediate abdominally based free flaps. Complications included one hematoma requiring evacuation and one displaced implant requiring revision. There were no positive subareolar biopsy results, and the nipple viability was 100 percent. Mean follow-up time was 10.5 months. Conclusions: The authors’ experience demonstrates that nipple-sparing mastectomy can be offered to patients with a history of reduction mammaplasty or mastopexy with reconstructive outcomes comparable to those of nipple-sparing mastectomy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.

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.

Infection after augmentation gluteoplasty in a pregnant patient.

The authors present a case of late postoperative infection after augmentation gluteoplasty in a 32-year-old pregnant woman. The case is unique in that it is the first documented example of a gluteal implant infection in a pregnant woman and because the infection was not preceded by trauma to the anatomic region.

Adipose stem cell therapy in cancer reconstruction: a critical review.

AbstractFound in most mesenchymally derived organs, mesenchymal stem cells are undifferentiated cells capable of developing into many cell types. Adipose stem cells are a type of mesenchymal stem cell easily extracted from lipoaspirate, often readily available, and are conformable to the tissue defect. Their ability for self-renewal, unlimited proliferation and proangiogenic, and immunomodulatory properties have made them attractive adjuncts in plastic surgery. Since the discovery of pluripotent cells in adipose tissue, plastic surgeons have applied the technology toward improving wound healing, soft tissue augmentation, and tissue engineering. More recently, some surgeons have used adipose stem cells in cancer reconstruction. By mixing lipoaspirate with concentrated fractions of adipose stem cells through a technique termed cell-assisted lipotransfer, plastic surgeons have claimed improved aesthetic results. Promising early results have been tempered by in vitro and animal studies demonstrating increased tumor proliferation and metastasis rates with the use of adipose and other mesenchymal stem cells. This review provides a succinct yet comprehensive overview of the current literature evaluating the oncologic risks associated with adipose stem cell use in cancer.

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate.

IMPORTANCE Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood. OBJECTIVES To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction. DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study. MAIN OUTCOMES AND MEASURES Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified. RESULTS Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = -0.61; P < .01). CONCLUSIONS AND RELEVANCE Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty. LEVEL OF EVIDENCE NA.