Breast Reconstruction Outcomes after
Nipple-Sparing Mastectomy and Radiation Therapy
Richard G. Reish, M.D., Alex M. Lin, B.S., William G. Austen, Jr., M.D., Jonathan Winograd, M.D., Eric C. Liao, M.D., Curtis L. Cetrulo, Jr., M.D., Barbara L. Smith, M.D., Amy S. Colwell, M.D..
Massachusetts General Hospital, Boston, MA, USA.
PURPOSE: Nipple-sparing mastectomy (NSM) has significantly increased in prevalence in recent years, and it has the potential for dramatically improved cosmetic results. Concomitantly, chest wall/breast irradiation is a common adjuvant for lumpectomy patients who later need mastectomy, and as adjuvant treatment for mastectomy patients who have opted for breast reconstruction. Furthermore, nipple reconstruction following skin-sparing mastectomy in patients with radiation has limited success. Few studies in the literature have examined outcomes of immediate breast reconstruction after mastectomy with nipple preservation and radiation therapy.
METHODS: Retrospective analysis of multi-surgeon consecutive implant-based reconstructions after nipple-sparing mastectomy from June 2007 to Dec 2012 was conducted at a single institution. Patient demographics, surgical technique, and patient outcomes including immediate complications, nipple or nipple areolar complex (NAC) removal due to malposition or close oncologic margins, and capsular contracture requiring open capsulotomy or reconstructive failure were analyzed in order to compare outcomes of irradiated patients with nonirradiated patients.
RESULTS: 605 immediate breast reconstructions were performed following nipple-sparing mastectomy. Of the reconstructions, 88 were treated with radiation therapy and 517 had no radiation. Preoperative radiation was administered in 43 while 45 received post-mastectomy radiation to the reconstruction. The mean follow-up period for all patients was 686 days. In comparing the group of patients with radiation to the group without radiation, the radiated patients were older (49.8 years vs. 45.9 years, p<0.001) but had similar BMI and smoking status (Table 1). The group with preoperative XRT had more single stage reconstructions (p<0.014) and lower implant volume (300cc vs. 386cc, p<0.001) than the patients without radiation. There was a trend toward more total complications in patients with radiation (19.3% vs. 12.8%) and a higher rate of implant loss (6.8% vs. 1.0% p<0.001). With regression analysis, preoperative radiotherapy had a higher rate of total complications (p<0.004, OR 2.225, C.I. 1.040-4.758) and postoperative radiotherapy had a higher rate of explant (p<0.003, OR 7.077, C.I. 1.926-26.003.) There were no significant differences in nipple removal secondary to malposition or positive oncologic margins in patients who received radiation compared to those who did not receive radiation. Patients with radiation did have a higher incidence of a secondary procedure for capsular contracture (12.5% vs. 2.3%, p<0.001) and fat grafting (13.6 vs. 3.9%, p<0.001). The total nipple retention rate in patients with radiation and nipple-sparing mastectomy was 90% (79/88), and the reconstruction failure rate was 8%. At 22 months mean follow-up, local recurrence occurred in 4/156 (2.6%) breasts operated on for cancer through 2011. There were no recurrences involving the nipple.
CONCLUSION: Nipple-sparing mastectomy and immediate reconstruction in patients who had or will receive radiation is associated with a higher incidence of complications and operative revisions compared to patients without radiation. However, the majority of patients have successful reconstructions with nipple retention at a mean 22 month follow-up with no recurrences detected in the nipple to date. Longer follow-up is warranted to assess for recurrent cancer, revisional surgery, and reconstruction failure.
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