A Novel Technique for Nipple-Sparing Mastectomy and Immediate Reconstruction in Patients with Macromastia

Sir: The aesthetic outcome of mastectomies can further be improved by combining nipple preservation and immediate breast reconstruction. In cases of macromastia with resultant excessive skin envelopes, a breast reduction type mastectomy is an option that can create an optimal aesthetic result. We performed a literature search to determine whether it would be theoretically possible to base a flap on a subdermal pedicle to supply the nipple-areola complex and thereby enable safe resection of all breast tissue while performing an excision of excess skin. We report three cases of nipple-preserving mastectomies using the Wise reduction pattern in combination with immediate tissue implant reconstruction to further enhance the aesthetic outcome. On review of the literature and anatomy, we found that there are constant intercostal perforators located between the fourth and fifth ribs deriving from the anterior and posterior branches of the intercostal artery. These perforators are clearly identified on microdissections and angiography studies. Based on these anatomical findings, we performed eight mastectomies while carefully preserving the intercostal perforators. The same technique was used in 10 cases of severe gynecomastia in male patients. Doppler ultrasonography was used for guidance preoperatively and for visualization of the perforators intraoperatively using the translumination technique (Fig. 1).Fig. 1.: Drawings illustrating the technique.A total of eight mastectomies with immediate reconstruction were performed using the above-mentioned technique. Two patients are illustrated below as examples. Also treated were 10 cases of severe gynecomastia in male patients. A 61-year-old woman with stage IV, poorly differentiated, papillary serous ovarian carcinoma who had undergone chemotherapy, total abdominal hysterectomy with bilateral salpingo-oophorectomy, and tumor debulking surgery was found to have a BRCA2 mutation on further workup. In light of the potential for breast cancer development in the future, the patient chose prophylactic bilateral mastectomies and requested immediate reconstruction. The patient denied any other previous medical problems, including peripheral vascular disease, vasculitis, autoimmune diseases, chronic steroid use, or smoking (Figs. 2 and 3).Fig. 2.: Preoperative markings.Fig. 3.: Transillumination of pedicle to visualize perforators and demonstrate thinness of the inferior pedicle flap.A 25-year-old woman presented who was the daughter of the aforementioned patient and who also tested positive for BRCA2 mutations and elected to undergo bilateral prophylactic mastectomies with immediate reconstruction (Figs. 4 and 5).Fig. 4.: View before closure.Fig. 5.: Postoperative view.With the patient in the standing position, an inferior pedicle reduction type incision is marked out with a broad base of approximately 10 cm. The inferior pedicle is deepithelialized using a scalpel, with care taken to preserve a maximal amount of dermis to preserve the dermal plexus and maintain all visible perforators. Of note, the use of the VersaJet-system was used for half of the cases and was found to be very helpful in deepithelializing the flap and decreasing operative time. Bilateral subcutaneous mastectomies are performed by the surgical oncologist. Submuscular Siltex implants (Mentor Corp., Santa Barbara, Calif.) are placed submuscularly and supported with an AlloDerm (LifeCell Corp., Branchburg, N.J.) sling. A subcutaneous pocket for the filling port is created and the expanders are filled to 40 to 60 cc of normal saline. Ten flat Jackson-Pratt drains are placed and a layered closure is performed. One patient developed some venous congestion on postoperative day 2 and was started on alternating nitroglycerin paste and Silvadene cream for 4 days, which led to complete resolution of the congestion. One other patient continued to smoke preoperatively and postoperatively. This patient developed partial nipple necrosis on both sides. All patients are currently very satisfied with their results. Whenever possible, immediate reconstruction in patients undergoing mastectomy should be performed to improve psychological outcome.1 The development of skin-sparing mastectomy technique with immediate reconstruction allows appropriate excision of the tumor with improved cosmetic outcome. The options and aesthetic results of immediate breast reconstruction are enhanced by the preservation of the inframammary fold in a skin-sparing mastectomy.2,3 Although some debate still exists regarding the use of skin-sparing mastectomy, the literature has proven that the local recurrence and overall survival rates are equivalent to those who underwent a modified radical mastectomy.4–7 The nipple-areola complex has significant psychological and aesthetic importance, particularly in women who have been diagnosed with breast cancer.8 In most skin-sparing mastectomies, the nipple-areola complex is resected with the specimen. The recreation of the nipple-areola complex is often performed months to years later following the final reconstruction with autologous tissue, implant, or tissue expanders. Although this approach can ultimately lead to adequate cosmetic results and patient satisfaction, it may also lead to loss of nipple sensation, pale nipple color, and loss of nipple projection as the scars soften with time.9 Over the past several years, some women have requested nipple-sparing mastectomies to preserve the appearance of a natural breast. However, preservation of the nipple-areola complex in the setting of breast cancer is controversial because of the reported increased risk of local recurrence. Studies evaluating occult tumor involvement in the nipple-areola complex have demonstrated a wide range of incidence, from 5 to 58 percent.10–14 Therefore, most oncologic and reconstructive surgeons do not advocate nipple-sparing mastectomies for cancer. Some women, however, are adamant in their desire to preserve the nipple-areola complex despite the associated increased risk. One study demonstrated that nipple and areolar invasion was a rare event, 1.2 percent, in women with early stage peripherally located tumors with a clinically normal nipple-areola complex.15 To further enhance the cosmetic outcome in macromastia patients, a Wise-type reduction pattern can be used to achieve a better breast shape while preserving the nipple-areola complex.15 It can therefore be argued that preservation of the nipple-areola complex is safe in women who undergo prophylactic mastectomies such as in our cases described. In the unlikely event of an occult tumor, the nipple-areola complex could still be sacrificed after the final pathologic results are obtained. Nipple-sparing mastectomy can be considered a safe surgical option for women with early disease distant from the nipple-areola complex such as in the cases described by us. Skin- and nipple-sparing mastectomy is a technically feasible and aesthetically pleasing option for a certain cohort of women when cancer is not located within 2 cm of the nipple-areola complex.16,17 It can be performed even in relatively large sized breasts, with low morbidity and very satisfactory cosmetic results.16,17 We describe using a Wise-type reduction pattern to achieve a better breast shape while preserving the nipple-areola complex. Especially in young BRCA-positive patients who undergo prophylactic mastectomies, the above-described technique of nipple-sparing mastectomy in combination with a Wise reduction skin pattern and immediate implant reconstruction can be considered safe while enhancing the final cosmetic result and decreasing the functional and psychological morbidity of the procedure. Niclas Broer, M.D. Deepak Narayan, M.D. Donnald Lannin, M.D. Baiba Grube, M.D. Yale University, New Haven, Conn.