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Total Skin-Sparing Mastectomy: Complications and Local Recurrence Rates in 2 Cohorts of Patients

Garwood, Elisabeth R. BS*; Moore, Dan PhD; Ewing, Cheryl MD*; Hwang, E Shelley MD*; Alvarado, Michael MD*; Foster, Robert D. MD; Esserman, Laura J. MD, MBA*

doi: 10.1097/SLA.0b013e31818e41a7
Surgical Technique

Purpose: Dissemination of the total skin-sparing mastectomy (TSSM) technique is limited by concerns of nipple viability, flap necrosis, local recurrence risk, and the technical challenge of this procedure. We sought to define the impact of surgical and reconstructive variables on complication rates and assess how changes in technique affect outcomes.

Patients and Methods: We compared the outcomes of TSSM in 2 cohorts of patients. Cohort 1: the first 64 TSSM procedures performed at our institution, between 2001 and 2005. Cohort 2: 106 TSSM performed between 2005 and 2007. Outcomes of cohort 1 were analyzed in 2005. At that time, potential risk factors for complications were identified, and efforts to minimize these risks by altering operative and reconstructive technique were then applied to patients in cohort 2. The impact of these changes on outcomes was assessed. Logistic regression was used to determine the association between predictor variables and adverse outcomes (Stata 10).

Results: The predominant incision type in cohort 2 involved less than a third of the nipple areola complex (NAC), and the most frequent reconstruction technique was tissue expander placement. Between cohort 1 and cohort 2, nipple survival rates rose from 80% to 95% (P = 0.003) and complication rates declined: necrotic complications (30% → 13%; P = 0.01), implant loss (31% → 10%; P = 0.005), skin flap necrosis (16%–11%; not significant), and significant infections (17%–9%, not significant). Incisions involving >30% of the NAC (P < 0.001) and reconstruction with autologous tissue (P < 0.001) were independent risk factors for necrotic complications. The local recurrence rate was 0.6% at a median follow-up of 13 months (range, 1–65), with no recurrences in the NAC.

Conclusion: Focused improvement in technique has resulted in the development of TSSM as a successful intervention at our institution that is oncologically safe with high nipple viability and early low rates of recurrence. Identifying factors that contribute to complications and changing surgical and reconstructive techniques to eliminate risk factors has greatly improved outcomes.

The impact of surgical and reconstructive variables on complication rates after total skin-sparing mastectomy is unknown. We compared the outcomes of total skin-sparing mastectomy in 2 cohorts of patients to assess how changes in operative and reconstructive technique employed in the second cohort affected outcomes.

From the *Department of Surgery, Carol Franc Buck Breast Care Center, †Department of Epidemiology and Biostatistics, and ‡Department of Surgery, Division of Plastic Surgery, University of California at San Francisco, San Francisco, California.

This work was supported partly by the Doris Duke Charitable Foundation.

Presented, in part, at the American Society of Clinical Oncology at San Francisco, CA, September 2007 and at the San Antonio Breast Cancer Symposium, San Antonio, TX, December 15, 2007.

Reprints: Laura Esserman, MD, MBA, Carol F. Buck Breast Care Center, 1600 Divisadero St Box 1710, San Francisco, CA 94115. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.