Delayed Nipple-Sparing Modified Subcutaneous Mastectomy: Rationale and Technique

Abstract

Abstract:The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective. Key Words: delayed nipple-sparing modified subcutaneous mastectomy, mastectomy, nipple-areola complex preservation T he inheritable breast cancer recently detectable by evidence of the BRCA-1 / BRCA-2 gene mutation, lobular hyperplasia, atypical ductal hyperplasia, and lobular carcinoma in situ are currently faced on a preventive basis with selective screening and follow-up, chemoprevention, and /or prophylactic mastectomy (1-4). The surgical options of simple mastectomy and subcutaneous mastectomythe former excising the nipple-areola complex (NAC) together with the gland, the latter leaving intact the NACprovides 95 -99% and 90 -95% breast tissue removal, respectively, and thus being inadequate as to oncologic radicality (5). Therefore when risk of breast cancer is high, total mastectomy is the golden standard.A 13% increase (from 81% to 94%) of total mastectomies in cohorts of women with a family history of breast malignancy has been observed since 1995, followed by an high rate of reconstruction. Metcalfe et al. (6) report breast restoration in 60% of these patients, compared with 6 -13% of nonprophylactic mastectomies.Our study addresses the hypothesis of a new radical approach to subcutaneous mastectomy while retaining the integrity of the NAC, without leaving any gland stalk or parenchyma underneath, and thus obtaining complete clearance of the breast tissue. Primary reconstruction with subpectoralis prosthesis or two-stage replacement with an expander are the surgical options to complete the procedure in order to achieve satisfactory cosmetic results. This procedure addresses both cancer prophylaxis and stage I cancer treatment.

Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases

“…Some authors proposed an histological Fig. 2 Overall survival retroareolar evaluation before the mastectomy: Palmieri et al [24] by a surgical biopsy and Govindarajulu et al [25] by a mammotome in place of the traditional frozen section. We didn't explore this possibility since we can have an histological response before the end of the mastectomy in order to decide the NAC conservation.…”

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

“…However, while the rationale for this approach is reasonable, the addition of a different surgical stage may introduce possibilities for complications [65] . First proposed by Palmieri et al [66] , the two-stage concept of delayed NSM had the objective of complete removal of all breast tissue, including the lactiferous ducts. According to the authors, the first stage involves NAC autonomization by performing a periareolar incision to detach the ductus from the nipple.…”

“…Numerous incisions have been described by a variety of designs incorporating a periareolar approach, or other variations in the shape around the NAC [11][12][13][14][15][16][18][19][20][21][22]30,[33][34][35][36][37]39,59,61,63,[66][67][68] . Although the incision types vary with configuration, the impasse of the access incision with no complications has drawn attention in the great part of the studies [20,[25][26][27][28]30,33] (Figure 1).…”

“…Although the incision types vary with configuration, the impasse of the access incision with no complications has drawn attention in the great part of the studies [20,[25][26][27][28]30,33] (Figure 1). A critical survey shows that the procedure is normally performed by numerous approaches, but the greater part more than one type of incision is performed [11][12][13][14][15][16][18][19][20][21][22]30,[33][34][35][36][37]39,59,61,63,[66][67][68][69] . In fact, Endara et al [39] analyzed 48 NSM studies, of which 41 described details related to the type of NSM incision.…”

Nipple-Sparing Mastectomy – Extended Indications and Limitations

“…However, there are surgical options for skin incisions that are intended both to provide adequate access to breast tissue and muscles and to ensure the viability of the NAC by preserving its blood supply [30,42]. The choice of the appropriate surgical technique is critical and depends on biopsy scars, tumor location, reconstructive surgery, and NAC vascularization.…”