Breast reconstruction after mastectomy

Breast reconstruction after mastectomy with nipple–areola preservation

Nipple–areola preservation in the setting of mastectomy is perhaps the most recent oncoplastic technique.

Although this operation includes a total mastectomy rather than partial mastectomy, it is considered by many to be an oncoplastic procedure because the NAC is preserved. This has been the topic of some controversy because the general indications for mastectomy are that the tumor characteristics are such that a partial mastectomy is deemed relatively unsafe due to tumor size, location, or lymph node status. In these cases, the fear is that the NAC may be a harbinger of tumor cells. Previous studies have demonstrated that the incidence of tumor involvement of the NAC ranges from 12% to 58%. Lambert, et al have reviewed the factors that are predictive of nipple involvement in a study of 803 women. The factors that were statistically significant predictors of tumor involvement included advanced stage (III, IV), tumor size (>5 cm), number of positive lymph nodes, central or overlapping locations, and undifferentiated tumors. Laronga, et al at the MD Anderson cancer center have evaluated NAC involvement in 326 women having skin-sparing mastectomy and found an incidence of occult involvement in 5.6%. They found no difference in positivity based on tumor size, nuclear grade, or histological subtype.

The clinical experience following breast reconstruction in the setting of nipple–areolar preservation has been somewhat mixed but with a favorable trend.

Clearly, patient selection has been a critical determinant of outcome based on aesthetic and oncologic considerations. Nahabedian and Tsangaris have evaluated the aesthetic outcomes following NAC preservation in 14 breasts and demonstrated that areolar sensation was present in 43%, delayed healing of the NAC in 28%, NAC asymmetry in 50%, and secondary procedures related to the NAC in 36%. In 11/14 breasts, the reconstruction was in the setting of breast cancer with a local recurrence in 3/11 (27%). Despite these morbidities, patient satisfaction was achieved in 78% of women. Sacchini, et al have demonstrated a very low recurrence with an occurrence in 2/64 (3.1%). No woman had tumor involvement of the NAC.

Satisfaction scores were good to excellent in 87% of women who had cancer and 94% in women who did not have breast cancer.