• Archives of Reconstructive Microsurgery
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• v.23 no.2
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• pp.51-64
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• 2014

This study provides a systematic review of the literature on nipple-sparing mastectomy and necrotic complications in order to estimate the prevalence of necrotic complications and to investigate their significant predictors. A literature search was conducted using the MEDLINE and Ovid databases. A pooled analysis was performed for calculation of the prevalence of nipple-areolar complex (NAC) necrosis, mastectomy flap necrosis, and overall necrotic complications and to evaluate the relationships between necrotic complications and potential risk factors. A total of 44 papers were analyzed. The prevalence of overall necrotic complications was 13.7%, including 7.5% for NAC necrosis and 7.8% for mastectomy flap necrosis. Types of incisions showed significant association with the rates of NAC necrosis and mastectomy flap necrosis. Incisions involving the NAC showed a significantly higher rate of NAC necrosis than those not involving it. The prevalence of NAC necrosis was higher in the autologous tissue reconstruction group than in the prosthesis group. Active smoking and diathermy dissection were significant predictors of both NAC necrosis and mastectomy flap necrosis. The findings of this review suggest that there are several predictors of necrotic complications in nipple-sparing mastectomy. Appropriate patient selection, careful operative planning, and surgical technique refinements may reduce the risk of necrotic complications.

• Archives of Plastic Surgery
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• v.45 no.3
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• pp.229-238
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• 2018

Background Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. Methods All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. Results A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P<0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. Conclusions Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

• Archives of Plastic Surgery
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• v.34 no.5
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• pp.622-627
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• 2007

Purpose: Although the autogenous tissue transfer has been the mainstay of the breast reconstruction, concern for the donor site morbidity can lead to the superseded method using tissue expander with implant or permanent expander-implant. However, the additional procedure of tissue expansion possibly cause discomfort and raise the cost. We tried to verify the efficacy of using the saline-filled breast implant by itself for the safe and convenient immediate breast reconstruction modality if the patients have small, round and non-ptotic breasts and the sufficient breast skin can be saved with mastectomy. Methods: From July 2002 to July 2005, 29 breasts of 26 patients were restored only with the saline-filled breast implant immediately after the skin sparing or nipple-areolar skin sparing mastectomy in Asan Medical Center. A pocket with pectoralis major and serratus anterior muscle was created and the implant was covered with this muscle pocket. Simultaneous contralateral augmentation was performed in patients whose mastectomy specimen weighed less than 100g. Results: Using only the saline-filled breast implant resulted in the successful reconstruction with few complications including partial necrosis of nipple areolar skin (five cases, 17.2%), capsular contracture (three cases, 10.3%), hematoma (one case, 3.4%), depigmentation of areolar skin (one case, 3.4%), hypertrophic scar (one case, 3.4%), which were all healed by conservative management. There were no significant complications such as implant exposure and subsequent removal. Conclusion: Immediate breast reconstruction only with the saline-filled breast implant can be a satisfactory alternative option for the patients whose breast is small, round and non-ptotic, especially when the nipple-areolar skin of the breast is preserved in the mastectomy.

• Archives of Plastic Surgery
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• v.48 no.5
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• pp.483-493
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• 2021

Background Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes. Methods Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed. Results There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025). Conclusions Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.461-464
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• 2008

Purpose: Although the demand for the mammoplasty including reduction or reconstruction is remarkably increasing, the anthropometric measurement for the breast, especially about the nipple areola complex(NAC) of Korean women has not been reported recently. Therefore, the anthropometric measurement about the NAC was performed to suggest the standard size of NAC for Korean women. Methods: Two hundred and twenty five female volunteers in 20's through 50's were included for the study. Questionnaires including the diameter of NAC, the diameter, height of nipple, age, marital status, delivery and lactation history were distributed to the volunteers and collected. Results: The mean values of our study are as follows: the areola diameter is $30.93{\pm}10.07mm$, the nipple diameter is $10.21{\pm}4.14mm$ and the height of nipple is $6.54{\pm}3.74mm$. The diameter of nipple areola complex(NAC) is bigger in old ages. If the volunteers have the history of marriage, delivery and lactation, it is bigger, as well. The height of nipple closely related to individual characters except the correlation between height of nipple and age. Conclusion: It is important to have standard data for the nipple areola complex in order to have good aesthetic results of mammoplasty. Despite the importance, there are a few measurement data for the nipple areola complex(NAC) of Korean women. The result of our study is not the absolute parameter for breast surgery, however it can be used as the standard size for NAC in the Korean female during breast surgery.

• Archives of Reconstructive Microsurgery
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• v.21 no.2
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• pp.118-130
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• 2012

Background: Women receiving mastectomy usually prefer a single-stage surgical procedure without the need for additional surgery. Hence, nipple sparing mastectomy was introduced, and the follow-up data on the aesthetic outcome and recurrence of breast cancer were investigated in this study. Materials and Methods: The study subjects comprised 22 patients who received nipple-sparing mastectomy and immediate breast reconstruction using the free transverse abdominal rectus abdominis myocutaneous flap between June of 2007 and June of 2012. The patients' aesthetic outcomes were measured with 2 methods for the objective result: Breast size measurements and breast volume calculation both at preoperative phase and postoperative 1 years phase. Also, the patients' satisfaction was evaluated at postoperative 1 year with the self-assessment questionnaire. Follow up check for assessing cancer recurrence was performed for an average period of postoperative 1063 days. Results: First, in objective aesthetic outcome, there were no significant differences between the preoperative and postoperative results on both the breast size and the volume. Second, the patient satisfaction analysis scores were graded as very good in 15 patients (68.2%), and as good in 6 patient (27.3%). Most of the patients were very satisfied with our surgery method. Last, there was no local or distant recurrence in these 22 patients during the follow-up period. Conclusion: In this study, the nipple-sparing mastectomy achieved satisfactory results for the breast scar and shape with a single-stage surgical procedure, and the cancer recurrence rate was not significantly different from that of the conventional mastectomy. Besides, the nipple-sparing mastectomy is more cost-effective than the conventional mastectomy since it reduces the need for additional procedures. However, we think that it is necessary to determine the long-term outcomes about the recurrence rate.

• Archives of Plastic Surgery
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• v.41 no.4
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• pp.366-373
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• 2014

Background The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer. Methods We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision. Results 281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction. Conclusions Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.

• Archives of Plastic Surgery
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• v.45 no.5
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• pp.441-448
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• 2018

Background Previously, surveys have been used to investigate breast reconstruction statistics. Since 2015, breast reconstruction surgery after mastectomy has been covered by the National Health Insurance Service in Korea, and data from breast reconstruction patients are now available from the Health Insurance Review and Assessment Service (HIRA). We investigated statistics in breast reconstruction in Korea through statistics provided by the HIRA Big Data Hub. Methods We investigated the number of cases in mastectomy and breast reconstruction methods from April 1, 2015 to December 31, 2016. Data were furnished by the HIRA Big Data Hub and accessed remotely online. Results were tabulated using SAS Enterprise version 6.1. Results The 31,155 mastectomy cases included 7,088 breast reconstruction cases. Implant-based methods were used in 4,702 cases, and autologous methods in 2,386. The implant-based reconstructions included 1,896 direct-to-implant and 2,806 tissue-expander (2-stage) breast reconstructions. The 2-stage tissue-expander reconstructions included 1,624 expander insertions (first stage) and 1,182 expander-to-permanent-implant exchanges (second stage). Of the autologous breast reconstructions, 705 involved latissimus dorsi muscle flaps, 498 involved pedicled transverse rectus abdominis myocutaneous (TRAM) flaps, and 1,183 involved free-tissue transfer TRAM flaps, including deep inferior epigastric perforator free-tissue transfer flaps. There were 1,707 nipple-areolar complex reconstructions, including 1,565 nipple reconstructions and 142 areola reconstructions. The 1-year mean number of breast reconstructions was 4,050. Conclusions This was the first attempt to evaluate the total number of breast reconstruction procedures using accurate, comprehensive data, and our findings may prove valuable as a foundation for future statistical studies of breast reconstruction procedures in Korea.

• Archives of Plastic Surgery
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• v.38 no.4
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• pp.408-414
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• 2011

Purpose: To correct breast ptosis, reduction mammoplasty and mastopexy have been developed in a way that minimizes complications. Recently, as the mean age of breast cancer occurrence is decreasing, the need for breast reconstruction in patients with breast cancer is rising. If mastopexy is performed with breast reconstruction at the same time, the size of the normal breast and the new one is not quite different. We decided to apply Z-plasty, which is a widely-used technique in plastic surgery to lengthen or change the direction of tension of the tissue. Methods: From March 2008 to December 2009, we performed breast reconstruction in 6 patients with breast cancer and scar contracture. After breast reconstruction, mastopexy with Z-plasty was applied to correct the asymmetry. The new nipple-areolar complex is placed on the line connecting the midclavicle and the current nipple. The inferior border of the new areola corresponds with the inferior border of the original areola, and the superior border about 2 cm upward the original superior border. We drew two oblique lines connecting the medial end of the incision line lower to the nipple-areola complex and the lateral end of the inframammary fold for Z-plasty. The excess tissue between these two lines was removed and the new triangular flaps were put together. Results: The average age of patients was 42.6 years, aged from 36.1 to 48.1 The weight of removed tissue was between 54g and 95 g, with the mean of 74 g. The average distance from the midclavicle to the nipple was 24 cm before surgery, and 21 cm after the surgery. The average operation time per patient (1 mastopexy) was 45 minutes, and the patients were satisfied with the size and shape. Conclusion: Applying Z-plasty for the mastopexy on the normal breast ptosis is a relatively simple way to achieve symmetry in patients who need breast reconstruction.

• Archives of Plastic Surgery
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• v.48 no.1
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• pp.26-32
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• 2021

Background Although loss of sensation in patients with breast cancer after mastectomy followed by breast reconstruction is an important factor affecting patients' quality of life, the mechanism of sensory recovery is still unclear. Our study aimed to identify variables that affect sensory recovery, especially pain, in reconstructed breasts. Methods All patients with breast cancer who underwent mastectomy followed by immediate breast reconstruction, including nipple reconstruction or areolar tattooing, were included in this study. Sensation was evaluated in the nipple as an endpoint of sensation recovery of the whole breast. Patients rated pain severity using a 3-point verbal rating scale (VRS): grade 0, no pain; grade 1, mild to moderate pain; and grade 2, severe pain. The VRS was assessed by a single experienced plastic surgeon. Results In the univariate analysis, the odds ratio (OR) for sensation recovery was 0.951 for age (P=0.014), 0.803 for body mass index (P=0.001), 0.996 for breast volume before surgery (P=0.001), 0.998 for specimen weight after mastectomy (P=0.040), and 1.066 for the period between mastectomy and sensory assessment (P=0.003). In the multivariate analysis, the variables that showed a significant effect were age (OR, 0.953; P=0.034), the period between mastectomy and sensory assessment (OR, 1.071; P=0.006), and reconstruction using abdominal tissue instead of prosthetic reconstruction (OR, 0.270; P=0.004). Conclusions Based on our results, it can be inferred that aging has a negative impact on the recovery of sensation, breast sensation improves with time after surgery, and the recovery of sensation is better in prosthetic reconstruction.