Over time, mastectomy techniques have evolved with the goal of optimizing aesthetic outcomes for patients. The most recent advance in mastectomy techniques is the ability to preserve the entire nipple-areolar complex (NAC) skin through total skin-sparing mastectomy (TSSM). Total skin-sparing mastectomy is an extension of nipple-sparing mastectomy designed to provide equivalent aesthetic outcomes with the preservation of the appearance of the NAC, while also resecting the underlying nipple ductal tissue to ensure all breast tissue is removed at the time of mastectomy.
With TSSM, patients are able to maintain the entire breast skin envelope for subsequent reconstruction, while still achieving excellent oncologic outcomes.1–7
Although the technique has become increasingly adopted for both prophylactic and therapeutic indications,8–13 TSSM can present considerable technical challenges to surgeons, particularly in the initial learning period. Although the occurrence of ischemic complications can be minimized through certain technical modifications,3,14–16 complication rates vary and may be higher than those after skin-sparing mastectomy (SSM). Additionally, significant postoperative clinical management can be required when complications occur.
Despite these challenges, many surgeons offer the procedure to patients for the presumed psychological benefit of maintaining the appearance of a patient’s own NAC, and the presumed aesthetic benefit that can come with subsequent immediate breast reconstruction. However, although the aesthetic and psychosocial impact of immediate reconstruction after SSM has been well described,17,18 assessment of similar patient-reported outcomes after TSSM and immediate reconstruction has been limited. Prior evaluation of patient satisfaction and outcomes after TSSM has shown high levels of satisfaction, but these studies have all been somewhat limited by their retrospective design and heterogeneous populations.19–21 The goals of this study were to prospectively evaluate patient-reported outcomes and satisfaction after TSSM and immediate expander-implant reconstruction and to track these outcomes over time.
PATIENTS AND METHODS
All English-speaking patients scheduled to undergo TSSM and immediate expander-implant reconstruction were recruited preoperatively for enrollment in this study. The study was approved by our institution’s Committee on Human Research. Enrolled patients received the preoperative questionnaire from the BREAST-Q reconstructive module22 and completed it electronically before their mastectomy. All patients were then sent the postoperative questionnaire at 1 month, 6 months, and 1 year after mastectomy. Time points for evaluation were selected to track trends in satisfaction from the early postoperative period through the completion of expander-implant reconstruction. Patients who did not complete the preoperative questionnaire were excluded from the final analysis, as were patients who did not complete at least 2 of the postoperative questionnaires.
All questions in the BREAST-Q reconstructive module were included in the questionnaires used in the study except for questions specifically related to abdominal donor-site symptoms or appearance, which were excluded. Questions regarding outcomes after nipple reconstruction were modified to allow for assessment of nipple characteristics in women who had undergone TSSM with preservation of their nipple skin.
Questionnaires were scored by domain using the QScore software (Rasch Unidimensional Measurement Models Laboratory, Perth, Australia) developed for the BREAST-Q. Mean scores were calculated by domain at each of the 4 time points. The modified questions regarding nipple outcomes were additionally scored for each nipple characteristic using a 4-point Likert scale, with the lowest score of 1 given for “very dissatisfied” and a score of 4 given for “very satisfied.” In each domain, mean scores at each of the 3 postoperative time points were compared to the preoperative score using χ2 statistics, with P < 0.05 considered significant.
Our surgical technique for TSSM has been described previously.3 Briefly, the mastectomy is performed through a variety of incisions, most frequently inframammary or superior periareolar, with coring out of all nipple tissue (while preserving the NAC skin) performed once the rest of the breast tissue has been resected. Inframammary incisions are typically used in small-breasted patients with minimal ptosis, whereas superior periareolar incisions are used in larger-breasted patients with moderate ptosis to allow for lifting of the NAC. Periareolar incisions are limited to less than 1/3 of the diameter of the NAC to maximize perfusion to the NAC. Reconstruction is performed through immediate subpectoral tissue expander placement and complete expander coverage with either serratus anterior muscle or acellular dermal matrix. Minimal expander fill (50–150 mL) is done intraoperatively to minimize pressure on the mastectomy skin flaps. At the completion of the case, the preserved NAC skin is wrapped in Vaseline gauze and surrounded by layers of dry gauze covered with an occlusive dressing to help maintain the projection of the NAC. Patients receive oral antibiotics postoperatively, which are continued until surgical drains are removed. All prosthetic reconstruction is done in a 2-staged fashion, with permanent implant placement occurring a minimum of 3 months postmastectomy (Fig. 1). Expansion is typically started at 2 weeks’ postoperatively, with most expanders filled to approximately 30% to 50% of final fill volume at 1 month postoperatively. All breast reconstruction at our institution is performed by 2 senior surgeons (R.D.F. and H.S.).
Patient and Treatment Characteristics
In our patient cohort, the survey completion rate was 55%; BREAST-Q scores were calculated from responses from 28 patients. Patient and adjuvant treatment characteristics are described in Table 1. Mean patient age was 47.8 years (range, 30.4–69.9); 64% of patients underwent bilateral reconstruction. No patients had undergone prior radiation therapy, although 14% had postmastectomy radiation. Of the 14 patients who received chemotherapy, most (79%) had neoadjuvant chemotherapy and the rest had adjuvant treatment.
Inframammary TSSM incisions were used in 54% of cases, whereas superior periareolar incisions were used in 46%. Complete submuscular coverage with serratus flap elevation was performed in 89% of cases and 11% of cases had acellular dermal matrix used for expander coverage.
Postoperative complications included 3 (10.7%) patients who developed mastectomy skin flap necrosis requiring operative debridement and closure. There were no cases of partial or complete NAC necrosis or expander-implant loss.
Mean scores for each of the domains at each of the different time points are shown in Table 2. Baseline mean breast satisfaction scores were high (69.8), but declined significantly to 46.6 at 1 month postoperatively (P < 0.001). Scores did improve over time, however, with overall breast satisfaction scores returning to baseline (mean score of 67.8) by 1 year postoperatively (Fig. 2). Satisfaction with outcome scores was also high (Fig. 3), with a mean score of 74.7 at 1 month postoperatively, which remained relatively stable on reassessment at 6 months and 1 year (mean scores of 67.5 and 68.1, respectively).
Mean nipple satisfaction scores were high throughout the postoperative period, with a mean score of 76.4 seen at 1 year postoperatively, although scores did decline over time (92.5 at 1 month, 81.6 at 6 months). Patient-reported assessment of specific nipple characteristics is shown in Figure 4. Nearly all patients were satisfied with the shape, appearance, and natural feel of their nipples at 1 year postoperatively. However, satisfaction with nipple position and sensation was much lower, with only 56% of patients reporting satisfaction with position and 40% with sensation at 1 year.
Subgroup analyses comparing patients who underwent bilateral reconstruction compared to those who underwent unilateral reconstruction demonstrated higher breast satisfaction scores at 1 year in the bilateral reconstruction group (63.3 vs 52), which trended toward significance (P = 0.18). Satisfaction with outcome scores was also higher in the bilateral group at 1 year (64.6 vs 51, P = 0.14). Comparison of patients who received postmastectomy radiation therapy to those who did not showed lower breast satisfaction scores at 1 year (60.9 vs 48), although the difference was not statistically significant (P = 0.24).
Well-being was assessed in 3 domains as follows: psychosocial, sexual, and physical. Scores in all 3 domains declined substantially at 1 month postoperatively compared to baseline (Fig. 5), with mean sexual well-being scores declining from 58.3 to 46.7 (P = 0.06), chest-specific physical well-being from 84.3 to 65 (P < 0.001), and psychosocial well-being from 75.7 to 67.4 (P = 0.2). However, scores improved over time, with scores returning to baseline by 1 year for sexual well-being (mean score of 57.7 at 1 year) and psychosocial well-being (mean score of 74.9 at 1 year); chest-specific physical well-being scores were still significantly lower at 1 year (72.5 vs 84.3 at baseline, P = 0.03), although had improved from earlier time points.
To our knowledge, this is the first study prospectively evaluating patient-reported outcomes after TSSM and immediate breast reconstruction, and tracking satisfaction and quality-of-life domains over time. Results from the study show high levels of overall breast and nipple satisfaction postoperatively and return of quality-of-life parameters to baseline level by 1 year after reconstruction.
Other studies examining aesthetic outcomes after TSSM and immediate reconstruction have primarily focused on surgeon-reported assessment of outcomes. A recent comparison of aesthetic outcomes after TSSM to those after SSM with nipple reconstruction23 showed significantly higher nipple appearance scores reported by independent observers for the TSSM group than the SSM group, as well as a trend toward higher overall aesthetic scores in the TSSM group. Other studies presenting a combination of patient-reported and clinician-reported outcomes have demonstrated moderate-to-high levels of patient satisfaction with aesthetic outcomes and good-to-excellent aesthetic outcome scores on photographic review,20,24 although the time lapse between reconstruction and survey administration varied widely in the patient populations in these studies. The patient-reported baseline breast satisfaction was high in our patient population, and although satisfaction declined significantly in the early postoperative period, levels returned to baseline by 1 year postoperatively.
Specifically focusing on nipple satisfaction, patients in the study reported overall high satisfaction scores with the appearance of their nipples after TSSM, particularly with the specific question of how natural their nipples looked postoperatively. Given that the desire to preserve the patient’s own NAC appearance and feel as much like their preoperative self as possible have been reported as motivating factors for undergoing TSSM,25 these data support the successful attainment of this goal of TSSM. However, patients reported lower satisfaction with nipple position and sensation. At our institution, TSSM is routinely offered to all patients unless the NAC is directly infiltrated by the breast tumor, which makes our TSSM patient cohort more heterogenous than those at other centers as it includes patients with large breasts and/or grade II/III ptosis. We have observed that decreased nipple satisfaction happens primarily in patients with large preoperative breast size and/or more significant ptosis.
Other studies examining patient-reported outcomes after TSSM have also described similar findings, particularly with regard to sensation.20,24,26 We have found that after TSSM, patients have much more breast skin sensation than patients who have undergone SSM, but that they rarely have sensation in the nipple itself. Given that most sensation to the NAC courses through the breast parenchyma, this diminished sensation seen in many patients is not surprising and unfortunately does not have an obvious solution for improvement; informing patients of this likely outcome is an essential part of the preoperative discussion to set appropriate expectations. Improving nipple position, on the other hand, may be more feasible. We have recently begun centralizing the NAC over the underlying expander and tacking the underside of the cored-out nipple skin to the pectoralis muscle before skin closure in an attempt to improve postoperative nipple position. Additionally, in patients who develop nipple malposition postoperatively, we will also attempt correction of the malposition at the time of expander-implant exchange through crescenteric excision of periareolar skin to adjust the NAC position in either the horizontal or the vertical direction. Through such techniques, centralization and appropriate nipple position is more routinely achieved.
In addition to evaluating patient satisfaction, the BREAST-Q provides valuable data on quality-of-life parameters after breast reconstruction.27,28 Assessment of quality-of-life scores in our study demonstrated significant decline in psychosocial, sexual, and functional domains in the early postoperative period, but return to baseline levels by 1 year postoperatively. This is consistent with other studies showing high quality-of-life scores after TSSM,21,26 although prior studies have not included preoperative evaluations to allow for comparison with patients’ baseline function and well-being.
The main limitation of this study is the absence of a group of patients who underwent SSM without NAC preservation to use for outcomes comparison. Over recent years, we have extended our indications for TSSM3 and now offer the approach to nearly all patients choosing or requiring mastectomy. With the limited number of patients currently undergoing SSM at our institution, a comparison of prospectively evaluated outcomes between groups was not feasible. Despite this limitation, however, the study design of evaluating patients preoperatively and then again at several different time points postoperatively allows for a more accurate assessment of functional and psychological outcomes and patient satisfaction with the procedure than a limited “snapshot” survey done once postoperatively. These findings can be used to help shape preoperative discussions with patients and establish appropriate expectations.
In summary, through prospective evaluation of patient-reported outcomes and satisfaction using a well-validated survey tool, results from this study demonstrated high levels of overall satisfaction and satisfaction with breast appearance at 1 year after TSSM and expander-implant breast reconstruction. High levels of satisfaction with nipple appearance and natural look of the nipples were also expressed, although lower reported scores for nipple sensation and position indicate potential areas for future technical improvement. As our intraoperative techniques for improved nipple positioning and fixation evolve, it is our hope that these scores will also increase in future patient cohorts.
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