KEY WORDS Breast reconstructive surgery - Nipple-areola complex position - nipple-areola complex
sparing mastectomy - prosthetic breast reconstruction
INTRODUCTION
Nipple-areola complex (NAC) preservation in female patient undergoing mastectomy for
breast cancer may improve patient satisfaction with better cosmetic results.[1 ]
[2 ]
[3 ]
[4 ] This technique was initially described in 2001 as a modification of skin sparing
mastectomy, and nowadays, it is performed both as prophylactic or therapeutic surgical
procedure. Many studies have revealed the oncological safety of this technique, particularly
when the tumor mass is far from NAC (4–5 cm).[1 ] NAC preservation has been demonstrated to be related to a better body image perception
if compared to skin reducing mastectomy (SRM), thus resulting in decreased psychological
discomfort.[2 ]
NAC-sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized
and non-ptotic breasts, while SRM is usually the best option in patients with medium-
or large-sized breasts with severe ptosis, planning surgical incisions as similarly
performed during mastopexies or reduction mammaplasties. In both cases, an immediate
prosthetic reconstruction can be performed, creating a complete submuscular pocket
to cover the breast implant.
The real “no men's land” is represented by patients with medium-sized breasts with
a moderate degree of ptosis. In those situations, neither NSM nor SRM are often associated
with optimal cosmetic results.[5 ]
NAC location on the reconstructed breast surface is a major factor in determining
the final aesthetic outcome and patients’ satisfaction. Thus, NAC placement on breast
maximum projection point, maintaining the symmetry with the contralateral breast (and
its NAC position), has a crucial role in determining the aesthetic outcome.[3 ]
In the present study, we report our personal surgical technique on 35 consecutive
patients to maintain NAC position after immediate one-stage breast reconstruction
with implants after NAC-sparing mastectomy.
METHODS
We selected 35 consecutive patients undergoing NSM for breast cancer treatment and
immediate one-stage prosthetic reconstruction. The average age was 46 ± 12 years (range
30–65) with a minimum 1 year follow-up. After informed consent was obtained, standard
pre-operative photographs were taken as follows to evaluate NAC complex position [Figures 1 ]
[2 ].
Figure 1: (a) Pre-operative standard photograph (anterior/posterior view – lateral view). (b)
Post-operative late standard photograph (anterior/posterior view – lateral view)
Figure 2: (a) Pre-operative standard photograph (anterior/posterior view – lateral view). (b)
Post-operative late standard photograph (anterior/posterior view – lateral view)
For each patient, we took a pre-operative photograph, an early post-operative photograph
(3–4 weeks) after surgery and a late post-operative photograph (1 year after surgery)
to assess the stability of NAC position overtime.
After NAC sparing mastectomy was performed, we elevated the pectoralis major muscle;
we harvested the recti muscles fascia and the serratus anterior muscle creating a
complete submuscular pocket. After accurate haemostasis was performed, we placed two
drainages (draining the submuscular pocket and the subcutaneous space, respectively).
We finally choose and placed the definitive breast implant and we sutured the muscular
layer.
Afterwards, we placed a suture stitch with the absorbable material (polyglactin) pinching
the retro-areolar tissue and fixing the NAC by hooking it at the pectoralis major
fascia in the desired position [Figure 3 ]. Subsequently, a classic intradermal suture was performed. Steri-strips were then
placed over the suture and a compression garment was applied.
Figure 3: (a) Nipple-areola complex – sparing mastectomy surgical incision. The implant has
been placed under a complete submuscular pocket. (b) The posterior aspect of the nipple-areola
complex is shown. (c) Suture is taken on the posterior aspect of the nipple-areola
complex. (d) Suture is taken on the pectoralis major muscle fascia. (e) Suture is
running from the posterior aspect of nipple-areola complex to the pectoralis major
fascia preventing nipple-areola complex depositioning after skin redistribution on
the post-operative period. (f) The nipple-areola complex is fixed on the maximum projection
point on the breast surface
The reconstructive outcome was evaluated comparing pre-operative and post-operative
photographs, and the results were assessed independently by five plastic surgeons
with expertise in breast reconstructive surgery considering NAC position and symmetry.
Patients’ short-term and long-term satisfaction were evaluated according to a 10-point
Likert scale, and the questionnaires were administered to the patients every 6 months
on the 1st year after surgery.
RESULTS
In all patients, we were able to place the NAC in the desired position on the maximum
projection point of the reconstructed breast. This result was stable at 1 year follow-up
in all patients despite skin redistribution overtime preventing NAC depositioning
[Figures 1 ]
[2 ]. The aesthetic outcome was satisfactory in all patients providing a stable symmetry
with the contralateral breast with high short-term and long-term patients’ satisfaction.
We did not observe any increase in the complication rate such as infection, seromas
and haematoma, and we had no partial or total NAC necrosis.
DISCUSSION
The final aesthetic outcome in patients undergoing NAC sparing mastectomy and immediate
one-stage prosthetic reconstruction is influenced by a great deal of factors such
as the selection of the most appropriate implant, accurate preservation of the NAC
vascularization and a proper symmetrisation mammoplasty. Furthermore, NAC position
is a leading factor determining the final reconstructive outcome and patient satisfaction,
and its stability overtime is a crucial issue that needs to be addressed during the
reconstruction. In our experience, patients with small-sized non-ptotic breasts usually
have an optimal pairing between muscular and cutaneous layers with a correct NAC positioning
at the maximum projection point on the reconstructed breast surface. Conversely, in
patients with medium-sized breast and medium-degree ptosis undergoing NSM, we observed
skin wrinkling caused by cutaneous excess with subsequent imperfect pairing between
muscular and subcutaneous layers. During the early post-operative period, spontaneous
skin redistribution over the reconstructed breast surface often corrects cutaneous
excess thus resulting in a significant NAC depositioning from the ideal maximum projection
point of the breast.
Planning a correct surgical incision together with the breast surgeon, choosing the
proper permanent implant, careful preservation of NAC vascularisation and accurate
contralateral symmetrisation mammoplasty patient's selection are the main factors
associated with an optimal reconstructive outcome after NSM. Nevertheless, in medium-sized/moderate
ptotic breasts, the final result can be significantly compromised by the previously
mentioned skin redistribution and NAC depositioning during the post-operative period.
In patients with the cutaneous excess described above, we tried to partially “fix”
the NAC position above the reconstructed breast applying steri-strips that pulled
the skin in the desired direction during the first 15–20 days after surgery. Results
obtained, albeit sometimes discrete, have proved to be often inconstant, not long-lasting,
only partially satisfactory and however, not effective and stable in all patients.
Thus, we tried to find a technical trick to make NAC position stable overtime. We,
therefore, devised an easy manoeuvre allowing us to achieve our target.
In our study, we report a simple and quick technical shrewdness that has been shown
to be totally devoid of early and late complications. We did not experience any increase
in the rate of prosthesis exposure and reconstruction failure, infection, seromas
and partial or total NAC.
CONCLUSION
Our experience in performing, this simple surgical technique is constantly growing,
and patients enroled in long-term follow-up show a great stability of the NAC position
overtime. Our post-operative observations are very encouraging, and we state that
this technique is safe and effective contributing to an optimal aesthetic outcome
with a high satisfaction rate among patients undergoing NSM and immediate breast prosthetic
reconstruction.
We, therefore, believe that this simple surgical trick should be performed in all
patients to optimise long-term reconstructive outcome.
Financial support and sponsorship
Nil.
