The pushing of boundaries in breast reconstruction continues.
Dr Charles Serrurier and Prof Carol-Ann Benn explain nipple-sparing mastectomies.
The surgical treatment of breast cancer has evolved from radical mastectomy with routine removal of the nipple-areolar complex (NAC) to breast conservative therapy with preservation of the breast and NAC. When breast-conserving surgery (BCS) is not appropriate due to tumour related factors, or the patient’s desire is for a mastectomy (either for risk reduction or cancer indications), conventional therapy still consists of mastectomy with removal of the NAC, followed by reconstruction. Rising interest in improved cosmesis has led to the introduction of the skin-sparing mastectomy (SSM) techniques and now nipple-sparing mastectomy (NSM), as alternatives to modified radical mastectomy.
Chasing the nirvana of the perfect breast reconstruction results in conflict between maintaining surgical oncological principles, while chasing more aesthetically pleasing and possibly better functioning reconstructed breasts.
The current item up for debate is the concept of NSM. The NAC is regarded as the signature of the breast or likened to the tip of a nose, and has significant aesthetic impact and has both sexual and psychological importance due mainly to its nerve sensation (erectile ability and erogenous sensation).
The current gold standard when required to do a mastectomy and reconstruction is a SSM with many reconstructive options, using either autologous (patient body tissue) or prosthetic options. This traditionally includes removal of the NAC and the skin over the tumour (if required), so as to ensure clear surgical margins. There are three groups of patient indications for SSM:
1. Patients who undergo the procedure for risk reduction (previously known as prophylactic mastectomies).
2. Patients with extensive duct carcinoma in situ (DCIS).
3. Patient with invasive breast cancer.
Clearly in patients undergoing risk reducing surgery with diverse indications, such as confirmed BRCA 1 and 2; strong family history of breast cancer; atypical ductal hyperplasia (ADH); lobular carcinoma in situ (LCIS); and other risk lesions, have extremely low recurrence rates irrespective of whichever technique is used. The reason for this is that the actual incidence of these patients developing breast cancer post mastectomy cannot be accurately quantified. Looking at retrospective studies on patients undergoing SSM for invasive cancer or DCIS, the nipple is affected by tumour cells in only 5-10% of cases. It is for this reason that the concept of NSM has been proposed.
There has been much controversy regarding the oncologic safety of NSM as well as the introduction of a set of complications, such as nipple and areolar necrosis, that were not a concern previously with a total mastectomy. Complicating these issues is the data analysis, the lack of randomised control trials, no long-term follow-up, and small isolated centre based retrospective audits.
Tumour contra-indication for NSM that are currently being considered includes the following list below. Patients with these disease processes should probably have a conventional mastectomy and not a NSM.
1. Paget’s disease of the nipple (i.e. cancer in the nipple).
2. Spontaneous nipple discharges with associated DCIS, (high incidence of nipple involvement).
3. Tumours close to the NAC.
4. Multicentric breast cancers (cancer throughout the breast).
5. Lobular breast cancers (with possible NAC involvement).
6. Inflammatory breast cancers.
Patients with diabetes, systemic lupus, other connective tissue diseases and smoking should be carefully considered for a NSM as these medical problems result in poor blood supply or tissue healing.
Indications for NSM vary from one institution to the next. The following indications have been taken from different institutions and are listed from safest to least safe.
1. High-risk patients for bilateral SSM, as a risk reduction procedure.
2. Small isolated DCIS away from the NAC (definition of small is debatable).
3. Small invading breast cancers, with some institutes giving tumour size up to 3cm.
4. Axillary ultrasound and sentinel lymph node negative.
5. 2cm distance from the NAC to the tumour.
Looking at NSM in the risk reduction setting is critical as prophylactic mastectomy has been the subject of major publications by many international groups. Its oncology benefit is undisputed in patients with a genetic mutation. Nevertheless, to recap the principles of this surgery – its impact on quality of life; its psychological, aesthetic, sexual, functional and pain repercussions are such that it should not and must never be offered in an emergency situation. Multi-disciplinary unit patient counselling involving discussions with other patients, onco-psychological assessment and discussions around the reconstruction should occur prior to patients undergoing the procedure.
Technical problems with the procedure may be avoided by careful patient selection. Reconstructive difficulties would occur in patients who have large breasts or very ptotic breasts, and may require the use of mastopexy type SSM. The nipple-blood supply in these settings is often further compromised. Clearly, the most significant concern is nipple viability followed by flap necrosis. There are complications that can potentially occur after a NSM:
1. Partial necrosis of the nipple with residual depigmentation.
2. Sloughing of the NAC.
Fortunately, they’re usually relatively easy to treat, however, these complications may require another short surgery to sort out.
Studies looking at patient satisfaction with objective observer assessments are few and far between. Important aspects to assess are appearance, symmetry, colour, position, and breast texture as well as nipple sensation and arousal. Most studies are small, however, most patients are satisfied with the appearance, symmetry, colour, position of the nipple and the breast texture. There is lower satisfaction amongst all patients with nipple sensation, most patients rating this as decreased compared to their pre-operative sensation.
Patient expectations must be addressed prior to the procedure – extensive pre-operative counselling and discussion needs to address expectations, aesthetic satisfaction, and long-term cancer control. Special emphasis needs to be made about decreased nipple-areola sensation. Assessing the patient’s body image and personality typing prior to the procedure also ensures better patient satisfaction.
NSM is a procedure that is gaining increasing visibility and acceptance. Provided that certain oncologic and practical criteria are instituted by the treating medical specialists; it has the potential for allowing improved cosmetic outcomes without increased oncologic risk in appropriately selected patients.
As we chase goals to ensure our patients, who are surviving breast cancer (due to improvements in oncology treatments), have better aesthetic outcomes, we need to ensure that rules are maintained to ensure safe long-term outcomes. It is wonderful that we can now add the NSM to this basket of clever reconstructive options.
MEET OUR EXPERT
Prof Carol-Ann Benn
Prof Carol-Ann Benn heads up breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.
MEET OUR EXPERT
Dr Charles Serrurier
Dr Charles Serrurier MBBCH [WITS], FC Plast. Surg. SA. is currently in full-time private practice as a breast reconstructive surgeon at Netcare Milpark Hospital. He performs most of his cosmetic surgery at his practice at Netcare Rosebank Hospital. His main interest is prosthetic based breast reconstruction and loco-regional flap based breast reconstruction.