Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients

doi:10.4236/jct.2012.325105

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Journal of Cancer Therapy, 2012, 3, 831-835

http://dx.doi.org/10.4236/jct.2012.325105 Published Online October 2012 (http://www.SciRP.org/journal/jct)

831

Nipple-Areola Sparing Mastectomy Followed by

Immediate Breast Reconstruction in 126 Patients

Xianming Wang, Min Wang, Jinkun Liu, Weicai Chen, Huisheng Wu, Shufeng Song

Center of Breast Diseases, Shenzhen Second People’s Hospital, Shenzhen, China.

Email: [email protected]

Received August 27th, 2012; revised September 26th, 2012; accepted October 4th, 2012

ABSTRACT

This study is to explore the indications, procedures, effectiveness, and feasibility of nipple-areola sparing mastectomy

followed by immediate breast reconstruction. The nipple-areola sparing mastectomy followed by immediate breast re-

construction was performed in 126 patients with breast cancer from June 2005 to October 2011. The cosmetic outcomes

of the reconstructed breasts were evaluated according to objective and subjective criteria. Meanwhile, the postoperative

complications were observed and the therapeutic efficacies were followed up. All the operations were successful. Six

patients experienced mild complications early after surgery and were resolved after symptomatic treatment. Both the

subjective and objective evaluation for the aesthetic outcomes yielded a satisfactory rate of 97.62% during the 6 -

80-month follow-up. No recurrence or metastasis was found in 118 cases. Nipple-areola sparing mastectomy followed

by immediate breast reconstruction is a simple and effective option for significantly improving the cosmetic outcomes

and quality of life of patients, without serious complications or impact on the comprehensive treatment and long-term

effect against breast cancer.

Keywords: Breast Cancer; Nipple-Sparing Mastectomy; Breast Reconstruction

1. Introduction

In recent years, orthopedic techniques are being increas-

ingly applied in the surgical treatment of breast cancer

[1]. The St. Gallen 2011 Expert Consensus has recog-

nized the cosmetic outcomes following extensive tumor

resection aided by orthopedic techniques [2]. Not only

does the reconstructive plastic surgery for breast cancer

compensate the resected breast in mastectomy, but it also

improve the safety and cosmetic outcomes of breast-

conserving surgery, thus improving the quality of life for

patients. Evidence-based medicine has confirmed that

skin-sparing mastectomy (SSM), comparably effective to

traditional mastectomy in treating breast cancer, is asso-

ciated with better cosmetic outcomes [3]. The nipple-

areola complex is essential in breast aesthetics. Nip-

ple-sparing mastectomy (NSM) is subcutaneous mastec-

tomy with nipple-areola complex left. A mastectomy that

retains the nipple and areola does not only simplify

breast reconstruction surgery, but significantly improves

cosmetic outcomes. Although the technical improvement

from SSM to NSM has been initiated, further research is

required to determine the eligible population in view of

the few long-term follow-up reports available. From June

to 2005 to October 2010, 126 patients with breast cancer

underwent nipple-areola sparing mastectomy followed by

immediate breast reconstruction in our hospital, achiev-

ing satisfying outcomes. The cases are reported as fol-

lows.

2. Materials and Methods

2.1. Study Design

The trial was a prospective cohort study and was ap-

proved by the ethic committee review boards of Shen-

zhen Second People’s Hospital, and enrollment began in

June 2005. Patients signed the informed consent forms

before operations.

2.2. Participants

The cohort included 126 female patients (Table 1) with

breast cancer aged 28 to 56 years (mean 43 years). Based

on TNM staging, there were 48 patients with stage 0

breast cancer, 23 cases with stage I stage 0 breast cancer,

and 55 with stage II stage 0 breast cancer. Overall, there

were 43 patients with ductal carcinoma in situ (28 with

negative sentinel lymph node biopsy and 15 without

axillary lymph node treatment), five patients with lobular

carcinoma (two with negative sentinel lymph node bi-

opsy and three without axillary lymph node treatment),

19 patients with stage I invasive ductal carcinoma, 52

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients

832

patients with stage II invasive ductal carcinoma, four

patients with stage I invasive lobular carcinoma and

three patients with stage II invasive lobular carcinoma.

Ninety-four patients did not have axillary lymph node

metastasis (including 42 with negative sentinel lymph

node biopsy). Of the thirty-two who did, twenty-five had

1 to 3 lymph node metastases and seven had 4 or more.

The molecular subtypes of the 78 cases of invasive car-

cinoma included 35 cases of LUMINAL A, 24 cases of

LUMINAL B, 9 cases of HER-2 ENRICH and 10 cases

of BASAL-LIKE.

Inclusion Criteria

1) Patients with stage 0 breast cancer with suspected

multifocal lesions or extensive calcification range; resid-

ual tumor along the needle tract was suspected in 15 pa-

tients despite definite diagnosis via minimally invasive

biopsy; non-Paget’s disease; 2) Patients with stages I and

II breast cancer (except T3N0 stage II breast cancer) with

a margin between the tumor and the areola of >2 cm, and

negative findings of subcutaneous tissues superior to the

tumor and subareola tissues near the lesion through in-

traoperative rapid pathological examination; 3) Patients

who had good overall conditions without serious heart

disease or cerebrovascular disease, and could tolerate

surgery; 4) Patients who met the requirements for breast-

conserving surgery but postoperative cosmetic expecta-

tions were poor due to small breast sizes; 5) Patients who

chose mastectomy due to concerns about the risk of re-

currence after breast-conserving surgery or unwillingness

to receive postoperative radiation therapy; 6) Patients

undergoing mastectomy in combination with prosthetic

implantation, also known as breast reconstruction sur-

gery.

2.3. Surgical Methods

All of the 126 patients underwent nipple-areola sparing

breast cancer resection and primary reconstruction with

silicone gel-filled breast implants. Incisions were made

along the outer edge of the breast, the areola or folds

under the breast following a curved shape for complete

removal of the breast tissue from skin and the surface of

pectoralis major. For patients whose incision was not

located at the outer edge of the breast, an additional inci-

sion was made at the armpit for sentinel lymph node bi-

opsy or axillary lymph node dissection. During separa-

tion beneath the nipple and areola, excessive division of

tissues posterior to the nipple should be avoided to pre-

vent postoperative ischemia and necrosis of the nipple

and areola. The breast reconstruction should be termi-

nated if positive pathological findings of the subcutane-

ous tissues under the tumor or subareola tissues near the

lesion were present.

Table 1. Baseline characteristics of patients.

Characteristic Patients (N = 126)

Age

Average 43

Range 28 - 56

TNM Staging

Stage 0 48

Stage I 23

Stage II 55

Pathology

Ductal carcinoma in situ 43

Lobular carcinoma in situ 5

Stage I invasive ductal carcinoma 19

Stage II invasive ductal carcinoma 52

Stage I invasive lobular carcinoma 4

Stage II invasive lobular carcinoma 3

Axillary Lymph Node

Positive 94

Negative 32

Prosthesis was implanted in the posterior space of the

pectoral muscle. The implant volume was calculated

based on preoperative measurement of the contralateral

breast. According to the measured volume of the contra-

lateral breast, a selected water-filled balloon was placed

into the space between the two chest muscles ipsilaterally

during surgery. In the present cohort, 85% patients had

relatively smaller breasts, and the volumes of used pros-

theses ranged from 180 to 240 mL. The space between

pectoralis major and pectoralis minor muscles, particu-

larly the lower edges, was completely divided and part of

the attachment of the pectoralis major to ribs was de-

tached to prevent asymmetrical appearance of the breasts

due to shift up of the prosthesis. Sufficient pads should

be used to support the upper and lateral sides of the

prosthesis during fixed dressing, and elastic tape was

used to simultaneously fix both the upper and lower sides

of both breasts in an oval shape so that both breasts were

at the same level. Intense activity of the upper limbs was

restricted in two weeks following the operation.

2.4. Aesthetic Evaluation of Breast

Reconstruction

2.4.1. M orphological Assess ment of Reconstructe d

Breasts

The appearance was classified according to the standards

of a previous report [4] as: 1) Excellent: breasts were

symmetrical, horizontal difference between nipples ≤ 2

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients 833

cm; normal appearance without significant difference in

shape compared with the contralateral breast; no breast

lift or deformation due to scar tissues, feel was good and

skin was normal; 2) Good: breasts were symmetrical,

horizontal difference between nipples ≤ 3 cm; normal

appearance or slightly smaller shape than the contralat-

eral breast; feel was slightly odd; and skin color became

lighter and then glossy; 3) Poor: breasts were asymmetric;

horizontal difference between nipples > 3 cm; obviously

deformed appearance and significantly smaller compared

with the contralateral side; feel was bad; skin was thick

and rough with rubber-like texture.

2.4.2. Patient Sel f- Assessment

Questionnaires were distributed among the patients 6 and

12 months after surgery, respectively, to determine their

satisfaction with breast reconstruction.

2.5. Postoperative Adjuvant Therapy

According to the clinical staging and molecular biologi-

cal subtypes specified in NCCN guidelines, postoperative

adjuvant radiotherapy, chemotherapy, endocrine therapy

and anti-HER-2 therapy were prescribed for all 126 pa-

tients. Conventional radiotherapy was administered for

seven patients who had four or more lymph node metas-

tases, and postoperative radiotherapy was given to six out

of nine patients who had one to three lymph node metas-

tases. The presence of prostheses did not affect the ef-

fectiveness of chemotherapy. Conformal radiotherapy of

the clavicle region could be prescribed for patients with

three or more lymph node metastases found in patho-

logical examination without affecting the prostheses [5].

3. Results

3.1. Postoperative Evaluation of Appearance

The satisfaction survey from six to twelve months after

surgery revealed that, of the 126 patients, 89 reported an

“excellent” morphological assessment of breast recon-

struction (70.63%), while 34 reported a “good” result

(26.98%). Both subjective and objective evaluation meas-

ures were at a satisfactory level (97.62%). Three patients

reported a “bad” outcome (2.38%), of which one experi-

enced significant prosthetic displacement at the early

stage of surgery and two developed prosthetic capsular

contracture during postoperative radiotherapy.

3.2. Postoperative Complications

Early after surgery, a slightly dry, solid and black ap-

pearance of the nipples was observed in three patients

due to poor blood supply. Although the wounds were

healed spontaneously without special treatment, they

were slightly smaller compared with the contralateral

ones. Subcutaneous hematoma was observed at the skin

folds under the nipples of two patients, and the wounds

were closed after removal of hematoma and pressure

bandage. One patient presented prosthesis displacement.

None of the remaining patients experienced flap necrosis,

effusion, wound dehiscence or other complications; pri-

mary closure of the wounds was achieved.

3.3. Follow-Up

The patients were followed up for 6 to 12 months and

97.62% of them were satisfied with the breast recon-

struction outcomes following surgery. In the follow-up

for 6 to 80 months, 15 patients (11.9%) had recurrence or

distant metastases, of which eight were regional recur-

rence (6.34%, including six cases of HER-2 ENRICH

and two of BASAL-LIKE) and seven were distant me-

tastases in 36 months after surgery (5.55%, including

five cases of HER-2 ENRICH and two of BASAL-LIKE).

Five of those patients died.

Another follow-up of 132 patients with stages 0, I and

II breast cancer who underwent breast-sparing surgery

over the same period revealed 17 patients (12.9%) of

recurrence or distant metastases, of which nine were re-

gional recurrence (6.81%, including seven cases of

HER-2 ENRICH and two of BASAL-LIKE) six seven

were distant metastases in 36 months after surgery

(4.54%, including four cases of HER-2 ENRICH and one

of BASAL-LIKE). Four of those patients died.

4. Discussion

The development of breast cancer therapy in the 21st

century has been steered by the important role of mo-

lecular spectra. The current consensus is also built upon

multi-disciplinary treatment by various means aided by

molecular classification of breast cancer. In recent years,

breast-conserving surgery has gradually been applied

across China, whereas the incidence of this technique

witnesses a decline in Europe and the United States [6,7].

This could be mainly explained by the following aspects:

1) The increasing application of BRCA genetic testing

has increased public awareness of prevention against this

condition; and preventive mastectomy with reconstruc-

tion has been used in clinical settings; 2) The universal

application of MRI and other imaging techniques has

increased the detection rate of many previously occult

lesions; 3) The addition of reconstructive plastic tech-

niques in the surgical treatment of breast cancer does not

only compensate the resected breast in mastectomy, but it

also improves the safety and cosmetic outcomes of

breast-conserving surgery, thus improving the quality of

life for patients.

Evidence-based medicine has confirmed that skin-

sparing mastectomy is comparably effective to traditional

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients

834

mastectomy in treating breast cancer, and there is con-

sensus that the extension of skin excision is independent

of local recurrence, so the skin-sparing technique is not

associated with an increased risk of local recurrence of

breast cancer [8,9]. The study of Fersis et al. [3] has

shown that postoperative local recurrence is mainly

caused by residual breast ductal epithelium cells rather

than breast skin tissues. Therefore, both approaches have

a comparable local recurrence rate after operation. The

nipple-areola complex (NAC) is an important part of the

female breasts, and salvage of the NAC is vital for the

cosmetic outcomes of breast reconstruction and postop-

erative quality of life. Laronga et al. [10] suggested a

correlation between the involvement of the nipple-areola

complex and lymph node metastasis, as well as the dis-

tance from the tumor to the edge of the areola, inde-

pendent of tumor size, histological type and receptors.

Therefore, nipple-areola sparing mastectomy is possible

in some breast cancer patients for whom the resection of

breast skin and the complex is unnecessary. In a clinical

trial, Gerber et al. [11] have shown that the retention of

the nipple-areola complex does not increase the risk of

relapse if the margin of lesions is farther than 2 cm from

the nipples. In a retrospective cohort study evaluating the

onset age, tumor size, axillary lymph node status, hor-

mone receptor status and HER-2 expression status of 47

patients undergoing the nipple-areola sparing modified

radical surgery, Wang Shengying et al. [12] found no

significant difference between the two groups in terms of

overall survival (OS), disease-free survival (DFS) and

local recurrence rate. This is consistent with the findings

in our follow-up comparison between the present cohort

and patients undergoing breast-conserving surgery over

the same period.

Breast reconstruction following mastectomy can be

divided into immediate (primary) and secondary opera-

tions. Compared with the secondary approach, imme-

diate breast reconstruction is advantageous [13,14] in: 1)

achieving mastectomy and breast reconstruction simul-

taneously so that patients will not “feel a loss” after the

initial operation; 2) reducing the required number of op-

erations and overall cost and avoiding pain from a second

surgery by accomplishing two procedures at one blow;

and 3) having no interference with postoperative radio-

therapy, chemotherapy and endocrine therapy. Based on

the source of materials used for reconstruction, the sur-

gery can be completed with either autogenous tissues or

prosthetic implants. While autologous tissue reconstruc-

tion is usually associated with large wounds, difficult

operations, high cost, obvious scars and high risk of

postoperative complications, prosthesis is a safe, fast and

simple option with little injury and short recovery period.

Studies have confirmed that the implantation of prosthe-

sis does not increase the risk of recurrence or develop-

ment of breast cancer, and thus silicone gel prosthesis

implantation is feasible and safe [11].

In the present study, we performed subcutaneous mas-

tectomy sparing the nipple, areola and skin of breasts in

strict compliance with the indication, and did not conduct

primary prosthetic implantation until it was confirmed

that no residual tumor cells were present beneath the nip-

ple-areola complex. The subjective and objective evalua-

tion of postoperative cosmetic outcomes was good in

97.62% of patients, which demonstrated the unique ad-

vantages of the technique in improving both aesthetic

effects and the quality of life of patients. Moreover, the

procedure did not affect the performance of postoperative

adjuvant therapy. The key to breast reconstruction is the

maintenance of symmetrical alignment of the skin folds

posterior to both breasts. When the folds are stripped

during mastectomy, the skin and the underlying tissues

should be sutured and fixed to form an alternative struc-

ture. The breast folds should be such fixed that the dis-

tance from the areola to the folds is equal to the contra-

lateral counterpart, otherwise the nipple may be prone to

skew and the lower half of the breast may lack fullness

[15]. Postoperative complications are common in patients

undergoing traditional mastectomy. Three patients had

compromised blood flow to the nipples, leading to partial

atrophy, which could be due to improper retention of the

vascular network in the subareolar layer. Crowe et al.

[16] noted that improper operation was a major cause of

necrosis of the retained nipple-areola complex. The blood

supply of the nipple-areola complex is mainly derived

from two circulatory networks—deep blood vessels in

the mammary gland and capillary network at the su-

bareolar layer. During operation of nipple-areola sparing

mastectomy, the deeper supply is interrupted and all

blood supply comes from the capillary network at the

layer 3 - 5 mm from the areola epidermis, which should

be protected [17]. Prosthesis displacement, a major risk

factor of poor cosmetic outcomes, was present in one

patient in the present cohort, as a result of excessive di-

vision of the posterior space to the pectoralis major and

improper postoperative fixation. Such displacement can

be effectively prevented by cutting off a part of the rib

attachment points of the pectoralis major to place the

lower edge of the prosthesis in the pectoralis major fis-

sures, so that the lower half of breasts can appear to be

nice and full. Postoperative radiotherapy has a certain

negative impact on breast reconstruction (two patients

experienced capsular contracture of the prosthesis). Hence,

tissue spacers may be implanted for patients with a clear

indication for radiotherapy, and replaced by the prosthe-

sis through secondary operation after the completion of

radiotherapy.

5. Conclusion

Based on the experience of the 126 patients undergoing

Nipple-Areola Sparing Mastectomy Followed by Immediate Breast Reconstruction in 126 Patients

835

nipple-areola sparing mastectomy (NSM) with primary

prosthesis implantation, we have found this technique

to be a simple and effective option for significantly im-

proving the cosmetic outcomes and quality of life of pa-

tients, without serious complications or impact on the

comprehensive treatment and long-term effect against

breast cancer. It is an effective option for surgical treat-

ment of breast cancer under clinical settings.

6. Acknowledgements

The study was supported by funds from Shenzhen Mu-

nicipal Bureau of Science and Technology (200801004).

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