Turkish Journal of Plastic Surgery

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 29  |  Issue : 1  |  Page : 14--19

Assessment of incision types, risk factors, and complication rates in nipple and skin-sparing mastectomy


Haluk Vayvada, Cenk Demirdover, Alper Geyik, Adnan Menderes 
 Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, School of Medicine, Dokuz Eylül University, Izmir, Turkey

Correspondence Address:
Dr. Alper Geyik
Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Faculty of Medicine, Dokuz Eylul University, Inciralti, Izmir 35340
Turkey

Abstract

Introduction: The incidence of breast cancer in the female population of reproductive age is rising. Surgery is the primary approach, and other treatment options can be adopted in certain circumstances. In the surgical field, lately, there has been a growing interest for nipple–skin-sparing mastectomy (NSSM). This study aims to emphasize the effect of incision types and patient characteristics (demographics, concomitant disease, smoking, history of radiotherapy, and chemotherapy) on complication rates. Patients and Methods: The subjects included 184 breasts in 92 female patients who underwent the NSSM procedure at our clinic from January 2010 to May 2019. Patients who underwent bilateral NSSM and immediate reconstruction with prosthesis were included in the study. Results: The most commonly used incision pattern was the inverted T-scar. Seven patients who had a contralateral prophylactic mastectomy (7.6%) were found to have atypical proliferative lesions or occult breast carcinoma in the clinically healthy contralateral breast on pathological examination. Complications were seen in 36 patients (39.1%). Skin–nipple–areolar complex necrosis was the most frequent complication. A previous history of radiation therapy was associated with higher rates of complications. Conclusion: NSSM and immediate single-stage implant reconstruction is a procedure with high morbidity and complication rates. The incision type and smoking have the main effect on complication rates. Although most complications are manageable, the surgical approach and patient-related risk factors should be taken into consideration for avoiding them.



How to cite this article:
Vayvada H, Demirdover C, Geyik A, Menderes A. Assessment of incision types, risk factors, and complication rates in nipple and skin-sparing mastectomy.Turk J Plast Surg 2021;29:14-19


How to cite this URL:
Vayvada H, Demirdover C, Geyik A, Menderes A. Assessment of incision types, risk factors, and complication rates in nipple and skin-sparing mastectomy. Turk J Plast Surg [serial online] 2021 [cited 2021 Jan 17 ];29:14-19
Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/14/305905


Full Text



 Introduction



Breast cancer still has a high mortality rate among women aged 40–55.[1],[2] The overall risk of getting breast cancer in the female population of reproductive age is 9.6%–13.1%, and the risk of death due to breast cancer is 3.4%.[3] Surgery is the primary approach for the treatment, and other modalities, such as radiotherapy (RT) and chemotherapy (CT), can be adopted according to clinical evaluation. There are several types of breast cancer surgery, and today, conservative breast surgery (CBS) is superseding the radical procedures.[4] CBS can be classified as wide local excision, quadrantectomy, and nipple–skin-sparing mastectomy (NSSM). Although there is still a lack of long-term data from current studies on NSSM, locoregional recurrence (LR) is evaluated at <1%/year, which is acceptable when compared to radical and modified radical mastectomies.[5]

According to the literature, women with unilateral ductal carcinoma in situ (DCIS) have an increased risk of developing either invasive cancer or DCIS in the contralateral breast. The annual risk is approximately 0.6%.[6] For invasive ductal and lobular carcinomas, this rate is even higher. Therefore, the surgeon should consider the risk while choosing the treatment option.

There is still controversy about performing risk-reducing prophylactic mastectomy to the contralateral side while performing the therapeutic NSSM. The certain indications for bilateral NSSM are fibrocystic disease with multiple biopsies that result in extensive scarring, lobular carcinoma in situ, atypical ductal or lobular hyperplasia, severe cellular atypia, florid papillomatosis, family history of bilateral premenopausal breast cancer, chronic mastitis with recurrent infections, and proven malignancy in a breast with suspicious mammogram findings on the contralateral side.[7]

This study aims to evaluate the effect of incision types and risk factors on complication rates and share our experience about the contralateral prophylactic mastectomy (CPM) procedure, which is still debatable.

 Patients and Methods



The subjects included 184 breasts in 92 female patients who underwent the NSSM procedure at our hospital from January 2010 to May 2019. Patients who underwent bilateral NSSM and immediate reconstruction with prosthesis were included in the study. Patients who underwent unilateral NSSM, simple mastectomy, modified radical mastectomy, and autologous or delayed reconstruction were excluded. Written informed consent form was obtained from all patients.

The plastic surgeon performed the physical examination and radiological evaluation, and patients with abnormal findings were subsequently directed to the surgery. All patients were evaluated at the Surgery and Oncology Academic Council. Depending on the decision of the council, tru-cut biopsy or wide local excision with or without sentinel lymph node biopsy was performed according to the frozen section result. If the sentinel lymph node result was positive, an axillary dissection was done. After the verification of breast cancer, the surgeon and patient mutually decided on the available treatment modality. Age, affected breast side, incision type, comorbid disease, pathology results of extensive local excision, smoking, complications, family history, and previous history of CT and RT were recorded. Incision types were divided into five main categories: inverted T-scar, inframammary, periareolar, previous operation scar, and free nipple. An algorithm for selecting the incisions was provided under the surgical procedure title [Figure 1]. Hypothyroidism, hypertension, and diabetes mellitus were included in the study as comorbid diseases. Complications were divided into two groups: implant-related and tissue-related complications. Patients who had first- or second-degree relatives with breast cancer were recorded as having a positive family history.{Figure 1}

Surgical procedure

Incisions were decided upon before the surgical operation, and the marking of the patients was performed according to this preoperative plan. Under general anesthesia, the surgeon made the incision with de-epithelization of the inferior quadrant. Then, the next step was elevation of the thin inferior-based lipodermal flap. We paid attention not to leave any breast tissue behind. Breast tissue was released from all peripheral quadrants. The subcutaneous tissue was left not more than 0.5 cm under the nipple–areolar complex (NAC) and lateral and medial pillars to avoid disrupting the flap's viability. Subpectoral pocket dissection was performed for the placement of the implant. Proper implants were inserted under the pectoralis major muscle, and the inferior quadrant of the implant was covered with the lipodermal flap.

Statistical analysis

The study design was retrospective, and we used Excel® (Microsoft Corp.) for medical data collection. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA). Differences among in-group categorical variables were compared using Chi-square and Fisher's exact tests, and the strength of the association between two variables was analyzed with phi and Cramèr's V tests.

 Results



The median age of the 92 patients enrolled in the study was 46.27 ± 1.41 years. The oldest patient was 62 years old, and the youngest patient was 31 years old. The mean follow-up period for patients was 23.2 months. Thirty-eight patients (41.3%) had breast cancer on the left, 35 patients (38%) had breast cancer on the right, and 10 patients (10.9%) had bilateral breast cancer according to tru-cut and wide local excision biopsy results. Eighteen patients (19.5%) had Stage 0 disease, 17 patients (18.4%) had Stage IA, 2 patients (2.1%) had Stage IB, 3 patients (3.2%) had Stage IIA, and 1 patient (1.08%) had Stage IIB disease. Patients who were diagnosed in other clinics and referred to our hospital with their pathology results were not included in the stage evaluation. We performed prophylactic mastectomies for nine patients (9.8%). Four patients had BRCA mutations, three patients had a family history and cancer phobia, and two patients had extensive multiple fibrocystic diseases. The main incision types were inverted T-scar, inframammary, periareolar, previous operation scar, and free nipple. The most common incision that we used for NSSM was inverted T-scar [Figure 1]. The relation between complications and incisions is shown in [Figure 2]. We did not find any significant difference (P = 0.023, P > 0.05) between inverted T incision, skin-NAC necrosis, and breast asymmetry (P = 0.72, P > 0.05). We only found a statistically significant difference between the periareolar incision and skin-NAC necrosis (P = 0.02, P < 0.05). Fourteen patients (15.2%) had hypothyroidism; four patients had hypertension and hypothyroidism; and two patients had hypertension, hypothyroidism, and diabetes mellitus. Pathological findings and stage of disease (atypical hyperplasia and breast cancer) were recorded before the NSSM procedure. Details are shown in [Table 1]. DCIS and invasive ductal carcinoma were the two main pathological findings before the surgery in patients undergoing bilateral NSSM. Seven patients (7.6%) had atypical proliferative lesions or occult breast carcinoma on the contralateral side. Twenty patients (21.7%) were actively smoking before the operation. Nine patients (45%) who were smoking had a complication after the surgery. Thirty-six patients (39.1%) had 39 tissue- or implant-related complications. In general, tissue-related complications were NAC or skin necrosis, breast asymmetry, wound dehiscence, and bad scar formation. Implant-related complications were implant malposition, implant exposure, and capsule contracture. Twenty-two patients (62.8%) had skin-NAC necrosis. Two patients who had necrosis also suffered from implant exposure and capsule contracture, respectively. Eight patients (22.8%) had breast asymmetry. One of eight patients' breast asymmetry occurred because of implant malposition. Three patients (8.5%) had wound dehiscence and bad scar formation. One patient had cancer recurrence in remnant breast tissue inferior to the areola, and one patient had superficial epidermolysis at the skin flaps. In the early postoperative period, one patient had a hematoma that was evacuated immediately. Twenty-two patients (62.8%) were operated on because of complications. Five of the patients were followed up conservatively. Operations were performed under local or general anesthesia, depending on the extent of necrosis or amount of asymmetry [Table 2]. We encountered one capsule contracture, one implant malposition, and one implant exposure. Thirty-one patients (33.6%) had a family history in their first- or second-degree relatives. Twenty-eight patients took both CT and RT individually or combined before NSSM. In addition, 15 patients who had taken CT and RT had complications after the operation.{Figure 2}{Table 1}{Table 2}

 Discussion



Women diagnosed with unilateral breast cancer are increasingly undergoing CPM. According to statistical analysis, CPM rates rose from 2% to 12.3% over a 10-year period. CPM effectively lowers the relative risk of contralateral breast cancer by approximately 95%, although it does not eliminate the risk. There is still a risk of developing cancer on that side after CPM, which ranges from 0.1% to 1.5%.[8] On the other hand, for carriers of BRCA1 or BRCA2, CPM seems beneficial because there is an annual risk of breast cancer of 3%–4%.[9] For women without BRCA1 or BRCA2 mutations, this risk is even lower. For this reason, nipple-sparing mastectomy (NSM) to the affected side and prophylactic mastectomy to the other side are not recommended according to guidelines.[10] As a result, studies suggest that, without hesitation, CPM should be discouraged for patients with an average risk of contralateral breast cancer.

When we analyzed our results, seven patients (7.6%) had atypical proliferative lesions or occult breast carcinoma on the contralateral side. The literature about CPM recommends reconsidering and using the indication carefully and explains the pros and cons of the operation in detail. According to guidelines, the UK Breast Cancer Clinical Reference Group (2016) states, “There is no evidence of a survival benefit for contralateral risk-reducing mastectomy this should not be offered, except for women with BRCA mutations, and should only be performed after a full discussion of the risks and benefits and with appropriate psychological support.” The National Institute for Health and Care Excellence has no recommendations about CPM, but guidelines were due for review in 2016/2017.

The European Society of Breast Cancer Specialists (EUSOMA) and EUROPA European Breast Cancer Coalition (EUROPA DONNA) do not have any published guidelines. Although we explain the treatment options to our patients generally, they prefer bilateral NSSM because of the ongoing risk to the contralateral side. The operation time is usually longer and the complication rate can be higher, but aesthetic outcomes for patient's perception after NSSM and immediate breast reconstruction are better depending on the literature.[11]

We mostly prefer inverted T-scar as a surgical incision [Figure 3]. The complication rate was 40%, and we did not find any significant difference between the inverted T incision, skin-NAC necrosis (P = 0.023, P > 0.05), and breast asymmetry (P = 0.72, P > 0.05). Even if the complication rate is high, this incision allows us to elevate an inferior-based lipodermal flap [Figure 4]. This random pattern thin flap and pectoralis muscle protect and cover the silicone prosthesis. If full-thickness skin necrosis occurs, skin grafts can be harvested over this lipodermal flap [Figure 5]. In addition, the lipodermal flap eliminates the need for using an acellular dermal matrix. We only found a statistically significant difference between the periareolar incision and skin-NAC necrosis (P = 0.02, P < 0.05). Rawlani et al.[12] mentioned that their study identified the periareolar incision as a risk factor for developing nipple necrosis during NSM.{Figure 3}{Figure 4}{Figure 5}

The periareolar incision resulted in nipple necrosis in 38.1% of breasts undergoing NSSM. For this group, our necrosis rate was 26.3% (5 of 19 patients), but they calculated the rate per breast. Our partial and total skin-NAC necrosis rate was 23.9%, which was higher than the literature.[13] However, these studies included only partial and total NAC necrosis. We routinely left approximately 0.5 cm of subcutaneous tissue so as to not disrupt the blood circulation in the flap, but sometimes, the flap thickness could have changed according to tumor size, location, and/or breast tissue distribution. Only minimal breast tissue was left under the NAC.

During the follow-up period, only one patient (1.08%) had cancer recurrence under the NAC; we did not observe any recurrence under the skin. In a pooled analysis, Headon et al.[14] found that, after NSSM, the LR rate was 2.38%. For skin-sparing mastectomy, they mentioned in a large systemic review that LR was only 0.9%; the recurrence rate on the skin was 4.2%. Fortunately, we did not have any cancer recurrence in skin flaps. Therefore, we strongly recommend defining the indications and contraindications for NSSM precisely.

Tumor spread, location, size, histological type, multicentricity and multifocality, and surgeon and patient preferences are important parameters when selecting the type of mastectomy. Sakurai et al.[15] followed up 788 patients who underwent NSM for an average of 78 months and reported a NAC relapse rate of 3.7% and an LR rate of 8.2%. We concluded that our recurrence rate was lower than the literature.

Breast asymmetry is another complication that discourages the surgeon. Because of variable tissue thickness, in the early postoperative period, the surface of the skin of the breast is rough. As time passes by, the surface meliorates and becomes smoother. If it persists, we prefer to do lipofilling to depressed areas of skin. Implant malposition is another reason for breast asymmetry. In our study, only one patient suffered from implant malposition.

BRCA1 and BRCA2 mutations are the most well-studied breast cancer susceptibility genes, accounting for 5%–10% of all female breast cancers. Developing breast cancer risk is higher in carriers of BRCA1 and BRCA2 mutations, and it is estimated to be as much as 70%.[16] Women who have a higher risk of breast cancer than the general population (such as those with BRCA gene mutations) may elect prophylactic mastectomy. Removing both breasts before cancer is diagnosed reduces the risk of breast cancer by 90% or more.[17] In our study, we performed nine prophylactic mastectomies; four of them (4.3%) had verified the BRCA1 mutation, and three patients demanded a mastectomy operation because of family history and cancer phobia. Two patients were tired of follow-up and requested NSSM. All patients in our study signed informed consent before the surgery and were informed in detail about its process, consequences, and complications.

Smoking is one of the factors that slightly increase the risk of breast cancer. The 2014 US Surgeon General's report on smoking concluded that there is “suggestive but not sufficient” evidence that smoking increases the risk of breast cancer.[18] However, it is well known that smoking is responsible for poor wound healing. Surgical outcomes appear to be worse, and complication rates are higher.[19] In our study, 20 patients (21.7%) were actively smoking before the operation. Nine patients (45%) who were smoking had a complication after the surgery. Statistical analysis revealed a significant difference in the complication rates between smokers and nonsmokers but failed to show a strong association statistically (P = 0.012, P < 0.05, phi = 0.26, P > 0.05).

This study had some limitations. The number of incisions was different. Skin-NAC necrosis and breast asymmetry were taken into consideration as complications for statistical analysis. The follow-up periods for patients were different, and we did not take into account the breast size and specimen weight. Similar to the literature,[12] the thickness of the mastectomy skin flap and the method of mastectomy flap dissection were not controlled precisely.

 Conclusion



Surgical orientation has seemed to change toward the NSSM. The growing interest and increasing number of articles confirm this orientation. However, there is still ongoing controversy about the incision types, indications, complications, unilateral or bilateral approach, cancer recurrence risk, and adjuvant treatment modalities. All studies on subcutaneous mastectomy emphasize different topics, and the conclusions are variable. As a result, we think that there is a relation between incision types and complication rates. The CPM procedure must be explained to the patient in detail because our occult carcinoma rate in the unaffected side was higher than that in the literature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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