Huston Tara L, Small Kevin, Swistel Alexander J, Dent Briar L, Talmor Mia
From the *Divisions of Plastic Surgery and †Breast Surgery,Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY.
Ann Plast Surg. 2015 Jun;74(6):652-7. doi: 10.1097/SAP.0000000000000004.
Nipple-sparing mastectomy (NSM) through an inframammary fold (IMF) incision can provide superior cosmesis and a high level of patient satisfaction. Because of concerns for nipple-areolar complex (NAC) viability using this incision, selection criteria may be limited. Here, we evaluate the impact of scarring from prior lumpectomy on NAC viability.
A retrospective chart review was conducted on a prospectively collected database at a single institution between July 2006 and October 2012. A total of 318 NSMs through IMF incisions were performed. We compared the incidence of NAC ischemia in 122 NSM cases with prior lumpectomy with 196 NSM cases without prior lumpectomy. All 318 mastectomies were followed by implant-based reconstruction. Clinicopathologic factors analyzed included indications for surgery, technical details, patient demographics, comorbidities, and adjuvant therapy.
The overall incidence of NAC ischemia was 20.4% (65/318). Nipple-areolar complex ischemia occurred in 24.6% (30/122) of cases with prior lumpectomy and 17.9% (35/196) of cases without prior lumpectomy (P = 0.1477). Among the 30 ischemic events in the 122 cases with prior lumpectomy, epidermolysis occurred in 20 (16.4%) and necrosis occurred in 10 (8.2%). Two cases (1.6%) required operative debridement. Seven cases (5.7%) were left with areas of residual NAC depigmentation. All other cases completely resolved with conservative management. There was no significant correlation between the incidence of ischemia and surgical indication, tumor staging, age, body mass index, tissue resection volume, sternal notch to nipple distance, prior radiation, single-stage reconstruction, sentinel or axillary lymph node dissection, acellular dermal matrix use, presence of periareolar lumpectomy scars, diabetes, or smoking history. At a mean follow-up of 505 days (range, 7-1504 days), patient satisfaction was excellent. Local recurrence of breast cancer occurred in 3 cases (2.5%), and distant recurrence occurred in 2 cases (1.6%).
Patients with scarring from prior lumpectomy do not have a higher rate of NAC ischemia and may be considered for NSM via an IMF incision.
经乳房下皱襞（IMF）切口行保留乳头的乳房切除术（NSM）可提供更好的美容效果和较高的患者满意度。由于担心使用该切口时乳头乳晕复合体（NAC）的存活情况，选择标准可能会受到限制。在此，我们评估既往肿块切除术瘢痕对NAC存活的影响。
对2006年7月至2012年10月间在单一机构前瞻性收集的数据库进行回顾性病历审查。共进行了318例经IMF切口的NSM手术。我们比较了122例有既往肿块切除术的NSM病例与196例无既往肿块切除术的NSM病例中NAC缺血的发生率。所有318例乳房切除术均采用植入物重建。分析的临床病理因素包括手术指征、技术细节、患者人口统计学特征、合并症和辅助治疗。
NAC缺血的总体发生率为20.4%（65/318）。有既往肿块切除术的病例中NAC缺血发生率为24.6%（30/122），无既往肿块切除术的病例中为17.9%（35/196）（P = 0.1477）。在122例有既往肿块切除术的病例中的30例缺血事件中，表皮松解发生在20例（16.4%），坏死发生在10例（8.2%）。2例（1.6%）需要手术清创。7例（5.7%）遗留有NAC色素脱失区域。所有其他病例经保守治疗完全缓解。缺血发生率与手术指征、肿瘤分期、年龄、体重指数、组织切除量、胸骨切迹至乳头距离、既往放疗、一期重建、前哨或腋窝淋巴结清扫、使用脱细胞真皮基质、乳晕周围肿块切除瘢痕的存在、糖尿病或吸烟史之间无显著相关性。平均随访505天（范围7 - 1504天），患者满意度良好。乳腺癌局部复发3例（2.5%），远处复发2例（1.6%）。
有既往肿块切除术瘢痕的患者NAC缺血发生率并不更高，可考虑经IMF切口行NSM手术。
