Toni Storm-Dickerson

Advances in Nipple-Sparing Mastectomy: Oncological Safety and Incision Selection

BACKGROUND With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum. OBJECTIVES The authors review their experience with NSM. METHODS From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM. RESULTS Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient. CONCLUSIONS NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.

Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results.

Summary: Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evaluation of an ultra‐lightweight, single‐patient‐use negative pressure wound therapy system over dermal regeneration template and skin grafts

As the use of negative pressure wound therapy (NPWT) over skin grafts has increased, traditional methods of NPWT system reimbursement and application are increasingly being challenged. A simplified method of accessing and operating NPWT in the outpatient setting is needed, particularly in cases where immediate outpatient use of NPWT is optimal. We evaluated use of a new ultra‐lightweight, off‐the‐shelf, disposable, single‐patient‐use NPWT system (SP‐NPWT; V.A.C.Via™ Therapy, KCI USA, Inc., San Antonio, TX) over dermal regeneration template (DRT) and/or skin grafts. SP‐NPWT was initiated over a DRT and/or skin graft in 33 patients with 41 graft procedures. Endpoints were recorded and compared to a historical control group of 25 patients with 28 grafts bolstered with traditional rental NPWT (V.A.C.® Therapy, KCI USA, Inc.). Average length of inpatient hospital stay was 0·0 days for the SP‐NPWT group and 6·0 days for the control group (P < 0·0001). The average duration of SP‐NPWT post‐DRT or skin graft was 5·6 days for the SP‐NPWT group and 7·0 days for the control (P < 0·0001). Preliminary data suggest that, compared to traditional NPWT, off‐the‐shelf SP‐NPWT may provide a quicker, seamless transition to home, resulting in decreased hospital stay and potential cost savings.

Prepectoral Revision Breast Reconstruction for Treatment of Implant-Associated Animation Deformity: A Review of 102 Reconstructions

Background Animation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Moving the implant from subpectoral to prepectoral has the potential to eliminate animation deformity. Objectives Describe the technique and outcomes of prepectoral revision reconstruction in over 100 cases and discuss patient selection criteria for a successful outcome. Methods Patients who presented with animation deformity following two-stage implant reconstruction were included in this retrospective study. Revision surgery involved removal of the existing implant via the previous incision site along the inframammary fold, suturing of the pectoralis major muscle back to the chest wall, creation of a prepectoral pocket for the new implant, use of acellular dermal matrix to reinforce the prepectoral pocket and completely cover the implant, and fat grafting to enhance soft tissue. Patients were evaluated for resolution of animation deformity and occurrence of complications during follow up. Results Fifty-seven patients (102 breasts) underwent prepectoral revision reconstruction with complete resolution of animation deformity. Complications occurred in 4 breasts (3.9%) and included seroma (2 breasts), skin necrosis (3 breasts), and wound dehiscence (1 breast). All 4 breasts with complications had their implants removed and replaced. There were no incidences of infection or clinically significant capsular contracture in this series. Conclusions Revision reconstruction with prepectoral implant placement and complete coverage with acellular dermal matrix resolves animation deformity and results in aesthetically pleasing soft breasts. Patient selection is critical for the success of this technique. Level of Evidence 4

Prepectoral Breast Reconstruction: The Breast Surgeon’s Perspective

Prepectoral breast reconstruction has been reemerging as a technique for postmastectomy implant-based reconstruction. Due to its advantage in eliminating animation deformity, shortening length of hospital stay and decreasing the amount of narcotics used for pain control, the technique has been embraced by patients and surgeons alike. The authors examined the breast surgeons perspective regarding prepectoral reconstruction taking into consideration oncologic criteria, breast cancer recurrence, surgical technique, and the team approach to patient care.

The Team Approach to Nipple-Sparing Mastectomy and Reconstruction

The goal of breast reconstruction is to recreate a breast that looks and feels like the natural breast. In order to achieve this goal, a collaborative approach to the surgical planning should be undertaken prior to any incisions. To have an excellent outcome in reconstruction, the plastic surgeon must have an excellent mastectomy flap quality. This is achieved by team work and communication between the breast surgeons and the plastic surgeons. The idea of a team approach to cancer care and breast reconstruction, once foreign, is now becoming the standard of care. With the evolution of breast care, advances in surgical techniques in mastectomies and reconstructions and availability of acellular dermal matrices, more patients are choosing and receiving breast reconstruction. Nipple-sparing mastectomy (NSM), once controversial, now has an expanding body of published experience, and is rapidly gaining momentum. NSM is evolving and should be considered a good treatment option in carefully selected patients.