LESS is MORE ONCOLOGICAL SAFETY OF NIPPLE SPARING MASTECTOMY: A SYSTEMATIC REVIEW AND ANALYSIS OF 12358 PROCEDURES with a focus on a new approach Am J Surg: Sept 2016 Arch Plast Surg: Aug 2016 Prof. Kefah Mokbel The London Breast Institute

Skin-sparing mastectomy (NSM) and ADM-assisted implant reconstruction Clinical outcome and patient satisfaction with the use of bovine-derived acellular dermal matrix (SurgiMend™) in implant based immediate reconstruction following skin sparing mastectomy: A prospective observational study in a single centre Kefah Mokbel Surgical Oncology, Vol. 25, Issue 2, p104–110 Published online: March 17 2016

Nipple sparing mastectomy: pioneered by Freeman 1962 Refers to… A method of mastectomy in which the nipple-areola complex is preserved in order to achieve a superior cosmetic outcome. Increasingly used for select patients with immediate breast reconstruction.

However, in carefully selected patients it could be a viable option. Issues Although resulting in a superior aesthetic outcome, nipple sparing mastectomy remains a controversial option. There have been questions regarding its oncological safety and concerns over whether it is associated with an increased risk of locoregional recurrence. However, in carefully selected patients it could be a viable option.

VS Nipple sparing mastectomy: is it safe? In the past: Oncological safety Cosmetic outcome VS However, nowadays cosmetic outcome and oncological outcome are regarded as dual goals.

Aims In this study, we gathered all relevant literature regarding the oncological safety and complication rates of nipple sparing mastectomy. We aimed to identify a group of patients who would be suitable for nipple sparing mastectomy. We also looked at our own experience with nipple sparing mastectomy via a periareolar incision

Inclusion criteria Female breast cancer patients undergoing nipple sparing mastectomy and breast reconstruction Studies had to clearly define whether patients had nipple sparing mastectomy or skin sparing mastectomy Studies had to report on locoregional recurrence and/or information regarding complication rates

Locoregional recurrence Outcomes The percentage of patients who had a recurrence of cancer in the breast Locoregional recurrence Including wound complications, skin necrosis, bleeding etc but not nipple necrosis rate Complication rate The percentage of patients who experienced nipple necrosis following surgery Nipple necrosis rate

…in total, 10395 patients with 12538 procedures Findings 73 studies identified 1970-2015: 91% retrospective 52 studies reported locoregional recurrence data 34 studies reported complication rates 55 reported on nipple necrosis rate …in total, 10395 patients with 12538 procedures

Results Outcome Result Local recurrence rate 2.38% Complication rate 12.3% Nipple necrosis rate 4.6%

Complications and nipple necrosis rates Clear reduction in complication rates after 2013, increased popularity/more experience etc

NSM vs. Conventional Mastectomy Sakurai et al, Long-term follow-up of nipple-sparing mastectomy without radiotherapy: A single center study at a Japanese institution, Med Oncol, 2013 A total of 932 patients between April 1985 and March 2004 were enrolled. 788 patients received NSM, whereas 144 patients received the routine mastectomy (No RT) No significant difference in 21 year DFS and OS

When is nipple sparing mastectomy a valid option ? Required Peripherally located tumour not involving the nipple, [>2cm away from the nipple areola complex] Sub-areolar tissue is histologically negative for malignancy Non-inflammatory breast cancer Preferable Positive ER/PR status and negative HER2 overexpression Unifocal and node-negative breast cancer < 5 cm

Technique Number of approaches exist: Periareolar with lateral extensions Trans areolar with periareolar and lateral-medial extension Incision choice Inframammary Italic S incision Aims: minimal scarring with optimal access to the mammary tissue whilst preserving adequate blood supply to the nipple-areola complex.

Focus on The Periareolar Approach Nipple-sparing mastectomy using a hemi-periareolar incision with or without minimal medial-lateral extensions; clinical outcome and patient satisfaction: a single centre prospective observational study

Technique We carried out nipple sparing mastectomies in 63 patients (96 procedures) using a periareolar approach. A superior or inferior hemi-periareolar incision with or without medial and lateral extensions of 5-10mm was performed. This allowed full dissection of glandular tissue. A small rim of 2-3mm of peripheral subcutaneous tissue was left behind the nipple to prevent necrosis. Retroareolar tissue specimen was sent for pathology to detect any tumour involvement- if any was found, the nipple was removed. Lipofilling was used to optimise the contours and aesthetic outcome in some cases.

Technique A single drain Prophylactic antibiotics LWMH for all GTN ointment/spray in selective cases Partial inflation intraoperatively in 2 stage reconstruction Median hospitalization = 2 days

Incision planning- periareolar incision

Nipple-sparing mastectomy

The use of ADM in implant-based reconstruction following NSM

Example of bilateral nipple sparing mastectomy and reconstruction

Incorporation of mesh

Example of skin sparing mastectomy and two stage reconstruction with nipple reconstruction on the right using SurgiMend™

Bilateral NSM & Implant-based Reconstruction

Right SSM and Left NSM (Implant-based Reconstruction and Nipple-Sharing

Nipple reconstruction using the nipple-sharing technique

Nipple reconstruction using a local flap

Bilateral nipple reconstruction using local flaps

Inflation of mammary implants

Bilateral NSM and ADM (mesh)-assisted implant-based reconstruction and subsequent periareolar mastopexy in a 39 year old doctor carrying the BRCA 1 mutation

Patient cohort Mean age: 47.5 years Mean BMI: 21.9 27% had chemotherapy 11.1% had radiotherapy 3.2% before surgery 9.5% post-mastectomy

Patient cohort

Outcomes No local recurrences with mean follow up 27.6 months No implant loss No nipple loss Wound complications in 2 patients (3.2%) One partial necrosis of areola No skin or nipple necrosis

Assessment of patient satisfaction: the BREAST-Q questionnaire The BREAST-Q is a patient-reported outcome (PRO) instrument designed to evaluate outcomes among women undergoing different types of breast surgery. Physical well-being Psychosocial well-being Sexual well-being Satisfaction with Breasts Satisfaction with Outcome Satisfaction with Care Patient Expectation

Patient satisfaction and aesthetic outcome Outcome measure Mean score (median, range) Breast Q questionnaire 87 (88, 62-100) Subjective assessment of cosmetic outcome 9.2/10 (10, 7-10) Objective assessment of aesthetic outcome 9.3/10 (9.5, 6-10) Capsular contracture score 2.6/10 (0, 0-10)

Left NSM & IBR: Slight malpositioning of nipple and stretched medial extension

Bilateral nipple sparing mastectomy for bilateral breast cancer : for fat transfer to left breast

Bilateral nipple sparing mastectomy for bilateral breast cancer ; The right reconstructed breast Here, the hemi-periareolar incision scar can be seen. As you can see the scarring is very minimal.

Process of fat transfer by lipofilling Fat transfer to left breast using the body-jet system Process of fat transfer by lipofilling

Fat transfer- post procedure

Conclusions Nipple sparing mastectomy is a suitable procedure in selected patients Safe, with low incidence of locoregional recurrence Low complication rates Excellent aesthetic outcome with high level of patient satisfaction Achievable via a periareolar approach

Thank You