Nipple-Sparing Mastectomy in the Community Setting

Fig. 8.1

Demonstrating the inframammary and axillary incisions for a left NSM

Fig 8.2

The breast is dissected off the pectoralis major fascia from both the inframammary and axillary incisions

Fig. 8.3

(a, b) Using a wireless gamma probe to locate a sentinel lymph node which is sent for frozen section analysis

A 12–14 cm incision at the inframammary fold is used to perform the NSM. The initial maneuver is performed by the plastic surgeon who frees the breast off of the pectoralis fascia through the inframammary incision. This dissection ultimately joins the release of the tail of the breast performed concurrently by the oncologic surgeon through the axilla (Fig. 8.4). Following this, the plastic surgeon assists in performing the mastectomy. The anterior mammary fascia is identified and the dissection is carried along this plane, dividing the individual Cooper’s ligaments with scissors beneath the dermis (Fig. 8.5a, b). This dissection preserves most of the subcutaneous fat layer with its subdermal plexus blood supply. No hydrodissection is used.

Fig. 8.4

Demonstrating the complete dissection of the breast off the pectoralis muscle

Fig. 8.5

(a) Preserving the subcutaneous fat layer by dissecting along the anterior mammary fascia. (b) Close-up picture of a Cooper’s Ligament arising from the anterior mammary fascia. The ligament is then divided under the dermis

For tumors close to the skin, high-resolution ultrasound is used intraoperatively to determine the extent of subcutaneous flap thinning (Fig. 8.6a, b). The subcutaneous fat is thinned in this location to the level of the superficial fascia. If the superficial fascia is involved, a subdermal dissection is pursued. If there is extension of the cancer into the overlying skin, the skin is excised.

Fig. 8.6

(a, b) Ultrasounding and marking the location of an infiltrating ductal cancer

The subcutaneous fat layer of the breast is absent beneath the NAC. Breast tissue adherent to the underside of the areola it is dissected free and the base of the nipple is divided sharply such that no breast tissue is left under the areola and nipple (Fig 8.7a, b). In all cases, a deep biopsy of the nipple base is taken and evaluated with permanent histology, not frozen section. The tissue expander is placed in either a pre- or retro-pectoral pocket and fixed in place and partially expanded. The mastectomy flaps are then closed over a single fluted drain externalized laterally through a separate incision adjacent to the inframammary fold (Fig 8.8a, b) Antibiotics given peri-operatively are continued orally upon discharge from the hospital until the patient’s drain(s) are removed.

Fig 8.7

(a, b) View of the dissected underside of the nipple-areolar complex. (b) Taking a biopsy of the base of the nipple

Fig 8.8

(a) Partially inflating a suprapectoral tissue expander with single drain in place. (b) Closure of both incisions

Figure 8.9a, b demonstrates the outcome of a 59-year-old female who underwent left nipple-sparing mastectomy for moderately differentiated invasive ductal carcinoma. Her history includes previous bilateral augmentation mammoplasty. A preoperative photograph is depicted on the left. She initially underwent prepectoral placement of a 275 cc tissue expander filled to a total volume of 120 cc. Five months later a 400 cc silicone gel implant was placed. The picture on the right is her final result nearly 2 years following final implant placement.

Fig 8.9

Pre-op (a) and post-op (b) views of a previously augmented 59-year-old female who underwent a left NSM

Our Experience

Over the past 11 years, the senior author (JKH) has performed 374 areolar sparing (AS) (n = 19) or nipple-sparing (n = 355) mastectomies (Fig. 8.10). A retrospective chart review was conducted on 237 patients (236 women and 1 male) who underwent either AS or NSMs during the time period November, 2004 through September, 2015. Pertinent patient data included patient age, sex, comorbid conditions, family breast cancer history, cancer type and stage, operative approach, complications, and neoadjuvant/adjuvant therapies. All 237 patients underwent disease characterization using digital mammography, high-resolution breast ultrasound, and breast magnetic resonance imaging (MRI). Additionally, each patient’s case was subjected to review at the weekly multidisciplinary breast conference . Nipple-areolar complex involvement, bloody nipple discharge, or inflammatory breast cancer precluded patients from undergoing AS or NSM. However, lymph node involvement, often necessitating neoadjuvant chemotherapy and/or postoperative radiation therapy were not considered exclusion criteria. The decision to proceed with mastectomy for cancer treatment was multifactorial and included patient choice, extent of breast involvement, and the presence of multicentric disease. One surgeon (JKH) performed all of the mastectomies included in this study and one plastic surgeon (AHS) performed the majority of the post-mastectomy reconstructions .

Fig. 8.10

Frequency of NSMs per year by the senior surgeon. Starting in 2012, NSMs were being performed more frequently at St. Joseph Hospital by other surgeons which impacted the senior surgeon’s experience

Two-hundred and thirty-eight (63.6 %) NSMs were performed in 227 patients for cancer intervention and 136 (36.4 %) were prophylactic. The average patient age was 51 years (range, 28–77 years). One-hundred one patients (42.6 %) had a family history of breast cancer, which included 31 patients (13.1 %) who were BRCA1/2 gene positive. It is important to note that not all patients underwent genetic testing. Past medical histories were significant for heart disease (n = 9), hypertension (n = 52), diabetes mellitus (n = 12), stroke event (n = 4) and smoking (n = 31). The histological composition of the cancers included invasive ductal (n = 165), ductal carcinoma in situ (n = 69), invasive lobular (n = 22) and malignant phyllodes (n = 1). There were two patients (0.54 %) with a positive biopsy of the nipple base, resulting in excision of the nipple-areolar complex during a subsequent operation. Of the patients who were BRCA1/2 gene positive, two patients who had not developed cancer underwent bilateral prophylactic NAS mastectomies. Twenty-two of the 29 remaining patients had risk-reducing contralateral prophylactic AS or NAS mastectomies.

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