Technical advances in mastectomy and reconstruction have improved our ability to restore the appearance of the native breast.1 A nipple-sparing mastectomy preserves the skin and nipple of the breast mound, thus allowing the possibility of a true 1-stage surgery where the breasts are removed and replaced in 1 operative setting.
In the past, a subcutaneous mastectomy with nipple preservation kept some of the breast tissue under the nipple to assist in perfusion. This technique was largely abandoned secondary to increased risk of cancer. In a sentinel article, Rusby et al.2 showed that the blood supply to the nipple could be maintained by a subdermal plexus with removal of the ductal tissue in the core of the nipple. Utilizing these principles, Smith et al.3 reported no recurrence or development of cancer in the nipple after 2,182 nipple-sparing mastectomies performed between 2007 and 2016 at our institute, and a 92.3% 5-year disease-free survival similar to skin-sparing procedures. In their large series, De Vita and Zoccali4 showed a low rate of 1.3% cancer recurrence in the nipple in 2,023 nipple-sparing procedures.
Acellular dermal matrix (ADM) or mesh materials support implant position and may have a protective affect against capsular contracture.5,6 The advent of ADM has changed the milieu of implant-based breast reconstruction and offers more natural, predictable results. If given a choice, most women would prefer to keep their nipples and have their breast reconstructed in 1 surgery if an acceptable result could be obtained. This is reflected in the trend toward increasing numbers of direct-to-implant (DTI) breast reconstruction seen in the United States.
The best candidates for nipple preservation are those with grade 1–2 ptosis.1 Although select patients with grade 3 ptosis may be considered, most of these patients require a staged approach to optimize nipple position.7 From an oncology perspective, a tumor to nipple distance of 2 cm or more is no longer required in many centers. Rather, our group suggests that the nipple may be viewed as another margin and thus free from cancer anatomically and radiologically, whereas Dent et al.8,9 propose that cancers within 1 cm of the nipple by magnetic resonance imaging can be safely considered for preservation. If the pathology shows a positive nipple margin, it must be removed. These patients are candidates for nipple reconstruction similar to skin-sparing and skin-reducing mastectomies.10
DTI reconstruction is considered for otherwise healthy patients with small-to-moderate–sized breasts who desire to stay approximately the same size.5,11 In some patients with large breasts, DTI may be offered if it is possible to fill the skin envelope with the implant or alternatively to tailor the envelope to accommodate a smaller sized implant. With experience, it is sometimes possible to increase the breast size; however, significant size changes are more safely performed in 2 stages. DTI is not typically offered to smokers or to patients with severe asymmetry.
Prior incisions on the breast from lumpectomy, augmentation, or breast reduction are not contraindications to NSM or DTI12; however, these patients are typically considered at higher risk for complications. At our center, we performed a comparative analysis of 775 implant-based reconstructions and found no significant increase in nipple loss or ischemic complications if a patient had a prior breast incision. In this series, 60% of patients were DTI. If there is concern about nipple viability in high-risk patients such as these, a nipple delay may be considered.13 This delay is performed around 3 weeks before the mastectomy with selective undermining of the nipple and mastectomy skin flap. An added advantage of this technique is that the retroareolar biopsy may be obtained to determine whether the nipple should be removed at the time of mastectomy.
An inferolateral inframammary fold incision is often used for the mastectomy14; however, a lateral radial incision may be considered if a periareolar scar is present to maximize nipple and breast skin perfusion. A lumpectomy scar that has been radiated is avoided to minimize wound healing and ischemic complications. Radiotherapy given before or after mastectomy is not an absolute contraindication to nipple preservation or implant reconstruction.15,16 Cases are evaluated on an individual basis to determine eligibility. Radiation increases complication rates in all types of breast reconstruction; however, the majority of patients have successful outcomes with maintenance of the reconstruction.
Planning the Incision
A team approach is important for planning the incision, location of the implant, and for managing adjuvant therapy. Of the incision choices, an inferolateral inframammary fold incision from approximately 6 o’clock to 3 or 9 o’clock on the breast maximizes cosmesis and may minimize complications once this access incision has been mastered1,14 (Fig. 1). A lateral radial incision anatomically preserves blood supply to the nipple and may be the safest choice for those initially starting the technique or if there are complicating scars on the breast. In the large breast, a vertical incision is often chosen to help center the nipple; however, the contractile forces place some tension on the skin and blood supply, thus making DTI reconstruction less likely when this incision is used.
Partial Muscle Coverage of the Implant
The most common technique for implant placement is with partial muscle coverage and ADM, although a prepectoral approach with ADM is gaining in popularity. The main advantage of partial muscle coverage is to decrease implant visibility in the upper pole of the breast. There is additional value in elevating the entire breast mound for bilateral reconstructions, long-term stability, and long-term low contracture rates. The disadvantage of partial muscle coverage is in animation with pectoralis muscle contraction. For most patients, this animation is mild; however, in select patients, it can be severe and debilitating. The main advantage of the prepectoral approach is in avoiding animation. In some cases of unilateral reconstruction, a prepectoral approach may provide better symmetry to the contralateral breast. The disadvantages of the prepectoral technique include the potential for more implant visibility in the upper pole and product cost. Furthermore, for posterior tumors and patients requiring radiotherapy, the team helps decide the best implant placement for radiation delivery and monitoring for recurrence. Total muscle coverage is rarely used in DTI reconstruction secondary to limitations in implant size and suboptimal shape.
The vast majority of women who get breast reconstruction choose silicone implants for the more natural look and feel compared with saline. An increasing number of choices are available for the plastic surgeon. The traditional smooth round implants are the softest. The smooth round implants with increased fill ratio are slightly firmer but may have advantages in breast reconstruction to help minimize rippling. The cohesive round or textured-shaped implants are the firmest and the least likely to show rippling. The textured-shaped implants are less mobile than the smooth round implants but may have advantages in improving nipple ptosis and in helping mitigate against contraction with radiation and with prepectoral reconstructions. Saline implants are rarely used in breast reconstruction. The exception is in very large breasts. Current saline implants can be filled to a volume of 960 cc, which is significantly higher than the maximum silicone implant size of 800 cc.
There has been no link between breast implants and breast cancer. However, a rare low-grade lymphoma designated breast implant–associated anaplastic large cell lymphoma has developed around breast implants in some women. The etiology of this anaplastic large cell lymphoma is largely unknown, but it has been observed more with textured devices.17
Once the style is chosen, the implant selection is based primarily on breast base width and volume. It is important to choose an implant that is wide enough to optimize centralization of the nipple position. This may require lower profile, less projecting implants, particularly in smaller sized breasts and single-stage reconstruction. If the base width of the implant is too narrow, the nipple will be lateralized. The volume of the breasts is estimated based on physical examination. Three-dimensional imaging can be used as an adjunct to physical examination to help predict volume and ensure the proper implants are selected for the case.
Patients are typically offered a paravertebral block before surgery to help with perioperative pain control. Increasingly, patients are offered an enhanced recovery after surgery pathway. The most common pathways include preoperative gabapentin and Tylenol, which may be continued for 1 week postoperatively.
The technique for partial muscle coverage with ADM has been well described5,18 The skin envelope is first assessed for perfusion and candidacy for DTI. If the skin is extremely thin with multiple areas of exposed dermis, or if there is deep red or blue discoloration with inflation of a sizer, then the patient is typically not a candidate for DTI. Insertion of the sizer at this early stage also helps determine volume and style choices for implants to make the pocket creation more accurate (See Video, Supplemental Digital Content 1, which shows the assessment of skin quality during DTI breast reconstruction following mastectomy, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C433). The pectoralis muscle is then elevated from its lateral and inferior borders to approximately the 4 or 8 o’clock position on the chest wall (see Video, Supplemental Digital Content 2, which demonstrates the process of pocket creation during DTI breast reconstruction following mastectomy, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C434). The ADM is sewn to the chest wall to serve as the lateral and inferior support structure for the implant and as an extension of the pectoralis muscle. The author prefers permanent sutures for this portion of the procedure (0 Ethibond) though absorbable sutures are preferred by others. A tight pocket is created approximately 1 cm more narrow than the diameter of the desired breast implant if human ADM is used to account for the inherent stretch of the product. A sizer is replaced into the subpectoralis-ADM pocket to check pocket dimensions and finalize the choice for implant size and style (see Video, Supplemental Digital Content 3, which shows how dimensions and final implant choice are assessed during DTI breast reconstruction following mastectomy, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C435). After implant placement, the pocket is closed tightly using absorbable sutures to avoid inferior or lateral malposition and to minimize the visibility of the pectoralis-ADM junction (see Video, Supplemental Digital Content 4, which demonstrates the implant placement and incision closure in DTI breast reconstruction following mastectomy, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C436). Two round drains are placed with 1 along the inframammary fold and the other spanning to the axilla and over top of the muscle. Care is taken to leave a soft-tissue bridge for the drain between the implant pocket and exit point to allow soft-tissue collapse and healing. If possible, these drains are placed above the level of the inframammary fold laterally to avoid a visible scar in a bathing suit. The skin edges are deepithelialized and closed in 3 layers using absorbable monofilament sutures (see Video, Supplemental Digital Content 5, which shows a skin closure technique during a DTI breast reconstruction following mastectomy, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/C437). The incision is sealed with a surgical glue and Tegaderm. Microfoam tape is often used to stabilize implant position.
Patients most often stay 1 night in the hospital. On postoperative day #1, a loose surgical bra is placed for support and for holding the drains. Showering can be resumed 48 hours after surgery since the incisions and drains are covered with Tegaderm. Drains are maintained until the output is less than 30 cc per 24 hours for 2 days. One drain is typically removed (from each side if bilateral) 1 week after surgery and the other is removed 2 weeks after surgery. Most commonly, oral antibiotics are maintained until drain removal. If smooth round implants are used, implant massage is begun at 4 weeks. Activity is restricted for at least 6 weeks after surgery.
In properly selected patients, outcomes from nipple-sparing mastectomy and DTI reconstruction are excellent and similar to 2-stage tissue expander reconstruction and skin-sparing procedures1,5,11 (Figs. 2 and 3). In one of the first comparative studies, we found that the complication rate in DTI reconstruction was similar to 2-stage reconstruction with an infection rate of 3% and explant rate of 1.5% per reconstruction. The cost of the ADM in DTI was offset by avoiding a second procedure. In our first 500 nipple-sparing mastectomy reconstructions, we found a low rate of complications, similar to our experience with skin-sparing mastectomy reconstructions. In this series, 60% of the reconstructions were single-stage. In contrast, Frey et al.19 reported higher rates of nipple and mastectomy skin flap necrosis with the DTI technique compared with tissue expander-implant reconstruction.
An important topic relevant to DTI reconstruction is revision rates. Revisions can be influenced by many factors including the quality of the reconstruction, complications, the patient’s desire or willingness to undergo another surgery, and the surgeon’s recommendation or willingness to suggest or perform a revision. With an average 5-year follow-up, we found a revision rate of 20.9% for DTI reconstructions.20 This was similar to our revision rate for tissue expander-implant reconstruction (20.3%) and included revisions for malposition, size, fat grafting, and capsular contracture. In this series, there was no difference in the 5-year rate of explantation (2.6% versus 2.3%; P = 0.829).
The most common acute complications include skin necrosis, infection, and seroma. The management of these is aggressive and better served by prevention if possible.
Skin necrosis occurs when the tissue demands exceed the body’s ability to deliver adequate nutrients and oxygenation. Inherent with a mastectomy, the blood supply to the breast skin is altered. This can be further compromised by excessively thin skin flaps that remove the subcutaneous fat or excessive traction on the skin during the dissection. If the skin perfusion appears jeopardized at the time of reconstruction, a tissue expander is placed or reconstruction is delayed to allow recovery. If an implant is placed and severe skin flap ischemia is observed postoperatively, consideration should be given to reoperation and placement of a smaller implant or expander. If skin necrosis ensues, this should be managed with excision. If a large amount of necrosis is present, the implant may need to be either removed or downsized to an implant/expander to allow closure without tension.
Prevention of infection includes meticulous technique, well-perfused skin flaps, avoidance of seroma, pocket irrigation, and perioperative antibiotics. Although the duration of routine antibiotic usage is the subject of much debate, none would argue with preoperative targeted intravenous antibiotics before the surgical start. When an infection occurs, treatment involves oral or intravenous antibiotics. If unsuccessful, operative washout with or without implant replacement is the next step in management. Following explantation, a tissue expander may be placed once the swelling and erythema have resolved. This typically takes a minimum of 3 months.
The extent of lymphatic disruption with a mastectomy is variable and increased when dissection extends to the latissimus dorsi muscle. Drains play a vital role in removing the excess fluid until the body is capable of managing the lymphatic flow. When a seroma develops, office drainage is the first step and it is often successful. If seromas persist, they may need to be drained operatively.
Nipple-sparing mastectomy and DTI reconstruction offers women a potential 1-step surgery where the breasts are removed and replaced in 1 setting. In properly selected patients, the complication rate is low and results are similar to what is achievable in 2 or more surgeries.
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