Conventional versus modified nipple sparing mastectomy in immediate breast reconstruction: Complications, aesthetic, and patient-reported outcomes

Abstract

Background: Nipple-sparing mastectomy (NSM) followed by immediate breast reconstruction (IBR) is the optimal surgical treatment for breast cancer. However, investigations are ongoing to improve the surgical technique to achieve better results. This study aimed to evaluate the outcomes of modified NSM (m-NSM), which preserves the anterior lamellar fat layer, in patients who underwent IBR.

Methods: All patients who underwent modified NSM (m-NSM) or conventional NSM (c-NSM) followed by IBR using autologous tissue or implants were retrospectively reviewed between January 2014 and January 2021. Two mastectomy types were compared in terms of postoperative complications and aesthetic outcomes using panel assessment scores by physicians and reported outcomes using Breast-Q. In addition, postoperative evaluations of the thickness of mastectomy flap was performed using CT scan images.

Results: A total of 516 patients (580 breasts) with NSM (143 breasts with c-NSM and 437 breasts with m-NSM) followed by IBR were reviewed. The mean ± SD flap thickness was 8.48 ± 1.81 mm in patients who underwent m-NSM, while it was 6.32 ± 1.15 mm in the c-NSM cohort (p = 0.02). The overall major complications rate was lower in the m-NSM group (3.0% vs. 9.0%, p < 0.013). Ischemic complications of the mastectomy flap and nipple-areolar complex (NAC) were more in c-NSM, although the difference was not statistically significant. The mean panel assessment scores were higher in the m-NSM group (3.14 (good) and 2.38 (fair) in the m-NSM and c-NSM groups, respectively; p < 0.001). Moreover, m-NSM was associated with greater improvements in psychosocial (p < 0.001) and sexual (p = 0.007) well-being.

Conclusion: Preserving the anterior lamellar fat in NSM was associated with thicker mastectomy flap, overall lower rates of complications, including ischemia of the mastectomy flap and nipple-areolar complex, and was associated with better aesthetic outcomes and improved quality of life.

Keywords: breast cancer; breast reconstruction; mastectomy; patient reported outcome; postoperative complications.

Figure 1

(A) Dissection plane in c-NSM: a dissection plane is on the superficial fascial plane, and the plane between pectoralis major fascia and muscle is a posterior plane of dissection; (B) dissection plane in m-NSM when the tumor is not close to breast capsule: anterior dissection plane is on breast capsule and posterior dissection plane is between pectoralis major fascia and muscle; (C) dissection plane in m-NSM when the tumor is in contact with the capsule of corpus mammae: anterior dissection plane is on superficial margin near the tumor which is same with c-NSM. c-NSM, conventional nipple-sparing mastectomy; m-NSM, modified nipple-sparing mastectomy.

Figure 2

Images show the intraoperative thickness of mastectomy flaps: (A) 42 years old patient with left breast cancer presented with c-NSM (BMI:23.61 flap thickness = 0.5 cm); (B) 39 years old patient diagnosed with right breast cancer is shown after m-NSM (BMI:25.21; flap thickness = 1.5 cm). c-NSM, conventional nipple-sparing mastectomy; m-NSM, modified nipple-sparing mastectomy.

Figure 3

Difference in mastectomy flap thickness between c-NSM and m-NSM on MRI images: (A) preoperative MRI image of the patient with right breast cancer; (B) one-month postoperative MRI image of the same patient after c-NSM and IBR using implant; (C) preoperative MRI image of another patient with right breast cancer; (D) postoperative MRI image after m-NSM and IBR using implant at 1-month follow-up; (E) 2x image of the breast shows the flap thickness of 4.92 mm after c-NSM; (F) flap thickness was 10.23 mm after m-NSM. c-NSM, conventional Nipple Sparing Mastectomy; m-NSM, modified Nipple Sparing Mastectomy.

Figure 4

The graphical illustration of the flap thickness using CT scan: (A) (a) midsagittal line; (b) a line drawn from line “a” to the lateral pole of the breast through the outer surface of the rib cage; (c) a line connecting the center of the most projected point of the nipple to the crossing point of the line “b” with the breast skin at the lateral pole; (d) a line connecting the center of the most projected point of the nipple to the crossing point of the line “b” with the line “a” in the midline; (1) and (2) points that divide the line “c” into three equal lines; (3) and (4) points that divide the line “d” into three equal lines; (B) (a) and (b) the flap thickness measurement points on the lateral pole of the breast; (c) and (d) the point of flap thickness measurement on the medial pole of the breast.

Figure 5

Intraoperative ICG angiography of mastectomy flap. (A,B) Color mode and fluorescence angiography of mastectomy flap after c-NSM. (C,D) Color mode and fluorescence angiography of mastectomy flap after m-NSM. ICG-indocyanine green.