1. LESS is MORE
ONCOLOGICAL SAFETY OF NIPPLE SPARING MASTECTOMY: A SYSTEMATIC REVIEW AND ANALYSIS OF 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

2. 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

3. 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.

4. 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.

5. 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.

6. 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

7. 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

8. 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

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

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

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

12. 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

13. 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

14. 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.

15. 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

16. 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.

17. 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

18. Incision planning- periareolar incision

19. Nipple-sparing mastectomy

20. The use of ADM in implant-based reconstruction following NSM

21. Example of bilateral nipple sparing mastectomy and reconstruction

22. Incorporation of mesh

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

24. Bilateral NSM & Implant-based Reconstruction

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

26. Nipple reconstruction using the nipple-sharing technique

27. Nipple reconstruction using a local flap

28. Bilateral nipple reconstruction using local flaps

29. Inflation of mammary implants

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

31. 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

32. Patient cohort

33. 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

34. 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

35. Patient satisfaction and aesthetic outcome
Outcome measure
Mean score (median, range)
Breast Q questionnaire
87 (88, )
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)

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

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

38. 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.

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

40. Fat transfer- post procedure

41. 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

42. Thank You