From the Departments of Plastic & Reconstructive Surgery.
General Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC.
Ann Plast Surg. 2021 Jun 1;86(6S Suppl 5):S521-S525. doi: 10.1097/SAP.0000000000002701.
Superior aesthetic outcomes can be achieved with mastectomy techniques that maximize breast envelope preservation and maintain the nipple-areolar complex. This is the impetus for the popularization of the nipple-sparing mastectomy (NSM). Nipple-sparing mastectomy is a challenging procedure due to potential ischemia of the mastectomy flap (which includes the nipple-areolar complex) and the risk of incomplete oncologic resection. We review our experience with NSM, identify technique modifications used over time, and evaluate reconstructive outcomes of NSM and its modifications.
A retrospective review of consecutive patients with NSM and breast reconstruction over an 8-year period was completed.
Fifty-five patients underwent 95 NSMs. Indications included invasive and in situ cancer, atypical ductal hyperplasia, and risk reduction. In the first 4 years of experience, the most frequently used NSM incision was radial (lateral) whereas use of a variety of incision patterns was noted in the second 4 years. Overall NSM and breast reconstruction complication rate for the entire study period was 50.9% and included a full-thickness mastectomy skin flap necrosis/nipple necrosis rate of 8.4%. In situ cancer of the nipple was identified in 3.2% of the patients, and 1 patient had locoregional recurrence. Overall complication rate was lower in the second 4 years of experience with NSM and reconstruction. One third of the patients underwent intraoperative fluorescent angiography (FA) to assess mastectomy skin perfusion before reconstruction start. Of the patients who had FA due to perfusion concerns, more than 70% of studies demonstrated poor perfusion and 83.3% of these patients had reconstruction delayed based on these results. Immediate, implant-based reconstruction was performed most commonly. An average of 2.66 procedures were required to achieve reconstruction completion, and 92.4% of the patients who sought reconstruction achieved completion.
At our institution, NSM use is increasing, NSM incision pattern types used are expanding, and complication rates are decreasing. Immediate, implant-based reconstruction is most commonly used in combination with NSM at our institution. Fluorescent angiography is used to assess mastectomy skin perfusion and likely limits mastectomy complication effects on reconstruction. Despite the occurrence of complications, most patients will complete the breast reconstruction process.
通过最大限度地保留乳房包膜并维持乳头乳晕复合体，可以实现更美观的乳房切除术效果。这是普及保留乳头的乳房切除术（NSM）的动力。由于乳房皮瓣（包括乳头乳晕复合体）可能发生缺血以及不完全的肿瘤切除的风险，因此保留乳头的乳房切除术是一项具有挑战性的手术。我们回顾了 NSM 的经验，确定了随着时间的推移而使用的技术改进，并评估了 NSM 及其改进的重建效果。
对 8 年来连续行 NSM 及乳房重建的患者进行回顾性研究。
55 例患者共行 95 例 NSM。适应证包括浸润性和原位癌、非典型导管增生和降低风险。在最初的 4 年经验中，最常使用的 NSM 切口为放射状（外侧），而在随后的 4 年中则使用了多种切口模式。整个研究期间，NSM 和乳房重建的总并发症发生率为 50.9%，包括全厚乳房皮瓣坏死/乳头坏死率为 8.4%。3.2%的患者发现乳头原位癌，1 例患者发生局部区域复发。NSM 和重建的经验在随后的 4 年中，并发症发生率更低。三分之一的患者在开始重建之前进行术中荧光血管造影（FA）以评估乳房皮瓣灌注。由于灌注问题而进行 FA 的患者中，超过 70%的研究显示灌注不良，其中 83.3%的患者根据这些结果延迟重建。最常采用即刻、植入物为基础的重建。平均需要 2.66 次手术才能完成重建，92.4%寻求重建的患者完成了重建。
在我们的机构中，NSM 的使用正在增加，所使用的 NSM 切口类型在扩展，并发症发生率在下降。即时、基于植入物的重建是我们机构中最常与 NSM 联合使用的方法。荧光血管造影用于评估乳房皮瓣的灌注情况，并可能限制乳房切除术对重建的并发症影响。尽管发生了并发症，但大多数患者仍将完成乳房重建过程。
