Dr. Christopher G. Trahan, MD, FACS

St. Charles Surgical Hospital &
Center For Restorative Breast Surgery
Nipple-Sparing

Nipple-sparing mastectomy (NSM) has now entered the mainstream for both the treatment and prevention of breast cancer. NSM in the past was known as subcutaneous mastectomy. In the 1970's, subcutaneous mastectomy was occasionally performed for fibrocystic disease, breast cancer prevention and less frequently for cancer. By the 1980's, reports of cancer occurring in the residual breast tissue led the procedure into disfavor. It was not until the last several years that this procedure was essentially reborn as nipple-sparing mastectomy.

In examining the studies of subcutaneous mastectomy done in prior decades it was apparent that there were several problems that led to relatively poor results. Most importantly, most subcutaneous mastectomies of the 1970's were performed with a focus on cosmetics and less concern about removing a maximum amount of breast tissue. In many instances breast tissue was left behind intentionally to improve cosmetic results and to prevent necrosis (death) of the nipple.

NSM is now usually performed by a surgical oncologist, breast surgeon or general surgeon, with a focus on maximizing breast tissue removal, while still attempting to maximize the cosmetic outcome. The term "nipple-sparing mastectomy" now refers to a more radical removal of breast tissue than was carried out during the subcutaneous mastectomy era. There has never been a comparative study that compares nipple-sparing mastectomy with standard or standard skin-sparing mastectomy. A skin-sparing mastectomy preserves the breast skin but does not preserve the nipple. There are large studies of skin-sparing mastectomies (SSM) that suggest results are likely similar to standard mastectomy techniques. However, as in NSM, no randomized comparative studies comparing SSM with standard mastectomy techniques have been carried out. At this time, there are no large studies of NSM followed for sufficient time to verify its ultimate safety. Because there are no studies to draw upon, surrogate information must be used to make a judgment as to its appropriate use.

Nipple-sparing mastectomy for cancer
Without comparative studies, investigators have focused on the risk of finding occult (not diagnosable by examination or imaging studies) cancer cells in the nipple in women undergoing mastectomy for cancer. There have in fact been at least 13 studies which have looked at the incidence of occult nipple involvement by carefully examining the nipple under the microscope after its removal for cancer. Each study has slightly different results but there is some general agreement as to what factors lead to an increase in risk of occult nipple involvement.

  1. Proximity of the cancer to the nipple: The closer the cancer is to the nipple the more likely cancer cells will be found in the nipple. Most investigators agree that at least 2 cm (a bit less than an inch) should separate the cancer from the nipple. Some investigators think that a 4cm distance is safer and utilize this distance in their recommendations.

  2. Tumor size: As tumors increase in size, whether invasive or non-invasive (DCIS), the incidence of occult nipple involvement increases. Investigators differ on whether 3 or 4 cm should be the cutoff.

  3. Lymph node involvement: A definite risk factor but not as significant as (1) or (2).

  4. Multicentricity (cancer in more than one breast quadrant): This factor was not examined by all studies but was significant in those where it was studied.

Nipple-sparing mastectomy for risk-reduction (prophylactic)

Women undergo risk-reduction mastectomy for a variety of reasons including:

  1. Testing positive for a mutation in the BRCA 1/2 genes.

  2. Strong family history of breast cancer without a positive genetic test.

  3. Women undergoing mastectomy for cancer and wish to reduce their risk in the opposite breast.

The issue with NSM for risk reduction centers around the milk ducts that exist in the nipple and the understandable concern that these ducts might serve as a source of new breast cancers. There are little in the way of actual studies that can support or deny that cancers actually arise in the ducts of the nipple. However, if one looks in the scientific literature, it will be difficult to find any studies that deal specifically with the risk of forming cancers in the nipple. (We are not speaking here about Paget's disease, which is cancer that has spread to the nipple from an underlying site in the breast.) Because cancers originating in the nipple have not been reported in the cancer literature, it seems reasonable to conclude that cancer originating in the nipple is rare or at the least, unusual. The low risk of nipple cancers may be at least partially explained by examining the actual anatomic origin of breast cancer. From very scholarly studies carried out in the 1970's, it has been discovered that virtually all breast cancers begin not in the large milk ducts similar to the ones found in the nipple but in the small microscopic ducts and milk-producing areas of the breast (lobules).

A study published by our group in 2008 in the Annals of Surgical Oncology examined this very question. We studied the nipple anatomy in patients undergoing mastectomy in which the nipple was removed. Our study found that the small ducts and lobules in which breast cancer arises were rare in the nipple. In the very few cases in which lobules were found, there were few in number and found only at the junction of the nipple with the underlying breast tissue and not near the tip of the nipple. From this study it seemed reasonable to conclude that because the anatomic structures needed to form a breast cancer were rare in the nipple, that cancer originating in the nipple should also be rare.

Technical Issues

Surgical complications related to nipple-sparing surgery are not unusual. The ability to get oxygen to the remaining breast skin is related to blood supply. The blood supply to the nipple and areola is particularly tenuous following NSM. Necrosis (tissue death) of the nipple-areola has been noted in virtually all reported series. It appears to vary from a high near 20% to a low of 2-3% (see full article). Many factors likely account for the differences including experience of the surgical team, choice of incision, breast size (increase risk in larger breasts) and on how effectively breast tissue is removed from behind the nipple and areola. In some circumstances, necrosis can occur to only the most superficial layers of the skin and complete healing usually occurs within a few weeks.

Some surgeons feel the need to intentionally retain breast tissue behind the nipple and areola while others feel that nothing short of an attempt to remove all visible breast tissue is appropriate. It should be noted however, that intentionally retaining breast tissue behind the nipple could be problematic particularly in patients carrying a BRCA 1/2 genetic mutation.

Patients electing to undergo NSM should also note that in almost all instances, the nipple will have little to no sensation. It is not unusual for some patients to note a return of sensation to the breast skin but few report a return of anything but the most minimal sensation in the nipple when complete removal of the breast tissue has been accomplished.

Summary

Nipple-sparing mastectomy is currently being performed with increasing regularity. It would be fair to say that it is still investigational. However, we do believe that it is a procedure that warrants serious consideration when mastectomy is needed to treat cancer or desired for risk reduction. In the cancer setting, strict selection criteria should be followed at all times (as outlined above) in order to minimize the risk of recurrent cancer in the nipple. Cancers greater than 2cm from the nipple, less than 4cm in size can be considered. Axillary node status and multicentricity should be considered on a case by case basis..

In the risk reduction setting, it is our feeling that there is minimal risk to retaining the nipple as long as great care is taken to remove all visible breast tissue from beneath the nipple. Coring of the nipple (removing tissue from within the nipple itself) should be considered in appropriate cases.

DIEP Flap

The DIEP flap employs skin and fatty tissue in the abdomen to restore the breast. The result in the abdomen is much like a tummy tuck in that the abdominal contour is often improved significantly as well. In contrast to the TRAM flap, the DIEP procedure does not sacrifice the muscles of the abdominal wall. This preserves the abdominal strength and avoids the need for implanted mesh.

Perforator flaps represent the state of the art in breast reconstruction. replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

"Stacked" DIEP Flap

Pioneered at our center, the "stacked Flap" provides another option for the thin woman who needs reconstruction of only one breast. This procedure allows for use of more abdominal fatty tissue than conventional TRAM procedures or single dIeP flap procedures. Using sophisticated microsurgical techniques, our surgeons are able to provide a greater volume to the reconstructed breast than has been historically possible. Our development of the "stacked Flap" has provided the opportunity for reconstruction with abdominal tissue for women who would have previously not been candidates.

Perforator flaps represent the state of the art in breast reconstruction. replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

SIEA Flap

In some women the superficial vessels in the abdominal fatty tissue provide the dominant source of blood flow to this region. In those cases the SIEA (superficial inferior epigastric artery) may be chosen as the source of blood supply for the borrowed tissue necessary to reconstruct the breast. The procedure is otherwise the same as the DIEP procedure and represents a second choice for women whose superficial vessels are more dominant than the deep inferior epigastric perforators (DIEP's).

Perforator flaps represent the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

SGAP Flap

For the thin woman or those with otherwise inadequate tummy tissue the breast may be reconstructed with tissue borrowed from the gluteal area. Skin, fat, and the tiny feeding blood vessels are collected without loss of underlying muscle tissue. The fatty tissue is removed from the excess in the upper hip providing a closure line that is concealed even in the most delicate of undergarments.

Perforator flaps represent the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

IGAP Flap

The IGAP is similar to the sGAP except that fat is collected from the lower hip and buttock.

Perforator flaps represent the state of the art in breast reconstruction. replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

Bilateral Simultaneous Immediate GAP Flap

Our center was the first to develop a protocol that allows those seeking reconstruction of both breasts the option of reconstruction in one operation when the tummy tissue is insufficient. Historically GAP flap procedures have been performed one breast at a time requiring two separate operations usually several weeks apart. The center for restorative Breast surgery now offers this option routinely to those women who are either thin and athletic or who for other reasons are not candidates for our procedures that borrow from the abdominal fatty excess.

Perforator flaps represent the state of the art in breast reconstruction. Replacing the skin and soft tissue removed at mastectomy with soft, warm, living tissue is accomplished by borrowing skin and fatty tissue from the abdomen or hip. This is accomplished without sacrificing muscles and strength as compared to less sophisticated techniques.

One Step Alloderm

Implant reconstruction may be considered for those who do not wish to pursue natural tissue reconstruction. Use of implants to restore breast volume is an option for carefully selected patients. Better candidates are those with C cup or less breast volume, thick skin, non-smokers, and those with early breast cancer or need for prophylactic mastectomy. Those who may/will require radiation therapy are considered poor candidates for implant reconstruction as the occurrence of significant capsular contracture is very nearly assured.

Implant reconstruction is preferentially performed with a fully preserved skin envelope as provided with a skin and/or nipple-sparing mastectomy. This avoids the need for expander placement and a separate surgery to exchange the expander to a permanent implant. This type of procedure is the latest advancement for those seeking implant reconstruction and is often called a "One Step Implant Reconstruction" although, at the Center for Restorative Breast Surgery, we believe it is more properly referred to as an Alloderm Assisted Implant Reconstruction. This procedure allows for placement of the final implant at the time of mastectomy. The implant is placed under the pectoralis muscle and supported from below with a sling of collagen sheeting known as Alloderm. This provides added coverage for the implant and relieves the skin envelope of the burden of the implant's weight.

Careful counseling is important since implant reconstruction differs substantially from the more familiar breast augmentation. The biggest challenge with implant reconstruction is that breast implants were designed to make healthy breasts larger not to rebuild an entire breast. So, they are affected by the same issues that affect any artificial device that is used to replace a part of the body. These devices, whether they are artificial joints, heart valves, or breast implants are subject to wear and failure over time. In the case of breast implants, this usually means a deflation or silicone leak that is addressed with a surgery to replace the implant. Rarely, infections can form around breast implants requiring their removal. Patients should expect the implant to be more palpable than is typical for a routine breast augmentation. Capsular contracture is the most common complication after implant reconstruction and occurs in between 30 and 90+% percent of cases. It is the formation of scar around the implant that makes the breast firm and in worst cases misshapen and painful. Your individual risk is unpredictable except for those who undergo radiation treatments who will nearly all develop it to a significant degree.

Breasts reconstructed with implants also have a tendency to move and distort shape when flexing the chest muscle. This isn't harmful to the breast but is something that should also be anticipated. Watch Video here.

Making an informed decision for those who are proper candidates can lead to a very successful implant reconstruction when combined with a skillfully performed mastectomy for those with breast cancer or need for prophylactic mastectomy.

Implant Reconstruction

With breast implants a surgeon is able to form a breast mound by using an implantable prosthesis. Breast implants are filled with saline (salt water) or silicone gel. The sacs are placed under your skin behind your chest muscle. Implants generally work well for the cosmetic breast augmentation patient because the tissue over the implant is healthy and relatively thick. Breast reconstruction with implants is very different from breast augmentation because the skin over the implant is left very thin following mastectomy. To compensate for this, the implants are placed "under the muscle" meaning under the pectoralis muscle. A side effect of this that is rarely discussed or mentioned to patients before surgery, is the tendency for the muscle to distort the implant and the reconstructed breast with movement. We have termed this "dynamic distortion" and it can be concerning for some patients (click to view example). Since this muscle usually only covers the upper 1/2 of the implant, Alloderm™ is used or the latissimus muscle (latissimus flap) is brought from the back to complete the pocket. The incision required for latissimus transfer is placed across the back and is typically visible in swimwear, low cut evening gowns, etc.
Implants are prosthetic devices and are subject to wear and tear. Most patients require re-operation at some point to address problems with their implants including leakage, deflation, infection, extrusion through the skin, capsular contracture (becoming hard), pain, and/or desire for size alteration. Implants are not considered lifetime devices. In fact, in 2002 a total of 59,292 women had breast implants removed, 15,785 of whom were reconstruction patients.
If you have had radiation therapy as a part of your treatment or radiation is likely for you following mastectomy, breast implants are often regarded as a poor choice. Radiation treatments make the breasts much more prone to harden after implant placement. As a result, most recommend reconstruction with your own body's tissue after radiation.

Lymphedema Surgery

The St. Charles Surgical Hospital is pleased to announce the opening of the first dedicated and comprehensive lymphedema treatment program of its kind. Our Lymphedema Treatment Center provides evaluation of those affected by arm swelling post mastectomy and full service solutions for improvement ranging from lifestyle counseling, massage therapy, compressive garment fitting and instruction, and, when indicated, surgical management strategies including the newest state of the art lymph node transplant procedures. The revolutionary Vascularized Lymph Node Transfer (VLNTx) procedure for lymphedema can be performed at SCSH when combined with any breast reconstruction surgery or as follow-up treatment to a previous surgery.

Lymphedema is a debilitating condition of localized fluid retention caused by a compromised lymphatic system. It is most frequently seen after breast cancer treatments such as lymph node dissection, surgery and/or radiation therapy, which can damage the lymphatic system of the arm. The National Cancer Institute has established that 25% to 30% of breast cancer surgery patients with lymph node removal and radiation therapy develop lymphedema. Chronic swelling, discomfort, and skin infections are among the symptoms that may be improved with proper therapy and in some cases, microsurgical repair. These groundbreaking techniques offer hope to those affected by lymphedema.

As leaders in the groundbreaking VLNTx technique, our Lymphedema Team evaluates those who may be candidates for surgical options and advises each candidate individually during their initial visit. For those with need of simultaneous breast reconstruction, a visit with the Breast Reconstruction Team can be coordinated in the same visit.

Poland's Treatment

Poland's syndrome (also known as Poland syndrome, Poland's syndactyly and Poland's anomaly) is a condition that can affect the development of the chest, breast, and upper extremity. It is present at birth but often goes undiagnosed until later in life since the severity of the effects varies from person to person. Poland's is more common in males than females and has been estimated to occur from one in 10,000 to one in 100,000 births.

Women with Poland's usually have underdevelopment of the breast on the affected side. This may range from a breast that is simply smaller than the other to complete absence of the breast and its associated nipple/areola. The large chest muscle (pectoralis) is also impacted and may be completely absent in some cases. deformities of the ribs and skeletal chest wall may also be present. These developmental shortcomings can be compared to a "congenital radical mastectomy" in the most severe cases.

Breast reconstruction is a commonly sought solution for the breast impacted by Poland's syndrome. Implant reconstruction is usually suggested as a first step but is made difficult by the lack of chest muscle to cover the implant and the shortage of skin and breast tissue to accommodate the implant. when implants are an undesirable choice or have failed to correct the breast deficiency, dIeP and GAP flap reconstruction can restore breast volume and shape with a natural and soft result.

Listen to an interview about Poland's Treatment with Dr. Dellacroce on Blog Talk Radio

BRCA 1 BRCA 2

Breast cancer is a common disease. Each year, approximately 200,000 women in the United States are diagnosed with breast cancer, and one in nine American women will develop breast cancer in her lifetime. But hereditary breast cancer - caused by a mutant gene passed from parents to their children - is rare. Estimates of the incidence of hereditary breast cancer range from between 5 to 10 percent to as many as 27 percent of all breast cancers.
In 1994, the first gene associated with breast cancer - BRCA1 (for BReast CAncer1) was identified on chromosome 17. A year later, a second gene associated with breast cancer - BRCA2 - was discovered on chromosome 13. When individuals carry a mutated form of either BRCA1 or BRCA2, they have an increased risk of developing breast or ovarian cancer at some point in their lives. Children of parents with a BRCA1 or BRCA2 mutation have a 50 percent chance of inheriting the gene mutation.

Alternatives

It is easy to get lost in the details and volumes of information on breast reconstruction, however, when things are broken down into their simplest terms, there are only 2 ways to reconstruct the breast.

  1. Breast Implants
  2. Your Own Body's Tissue

Breast Implants - With breast implants a surgeon is able to form a breast mound by using an implantable prosthesis. Breast implants are filled with saline (salt water) or silicone gel. The sacs are placed under your skin behind your chest muscle. Implants generally work well for the cosmetic breast augmentation patient because the tissue over the implant is healthy and relatively thick. Breast reconstruction with implants is very different from breast augmentation because the skin over the implant is left very thin following mastectomy. To compensate for this, the implants are placed "under the muscle" meaning under the pectoralis muscle. A side effect of this that is rarely discussed or mentioned to patients before surgery, is the tendency for the muscle to distort the implant and the reconstructed breast with movement. We have termed this "dynamic distortion" and it can be concerning for some patients (click to view example). Since this muscle usually only covers the upper 1/2 of the implant, Alloderm™ is used or the latissimus muscle (latissimus flap) is brought from the back to complete the pocket. The incision required for latissimus transfer is placed across the back and is typically visible in swimwear, low cut evening gowns, etc.

Implants are prosthetic devices and are subject to wear and tear. Most patients require re-operation at some point to address problems with their implants including leakage, deflation, infection, extrusion through the skin, capsular contracture (becoming hard), pain, and/or desire for size alteration. Implants are not considered lifetime devices. In fact, in 2002 a total of 59,292 women had breast implants removed, 15,785 of whom were reconstruction patients.

If you have had radiation therapy as a part of your treatment or radiation is likely for you following mastectomy, breast implants are often regarded as a poor choice. Radiation treatments make the breasts much more prone to harden after implant placement. As a result, most recommend reconstruction with your own body's tissue after radiation.

Your Own Body's Tissue ("Flaps")

  • TRAM Flap (Transverse Rectus Abdominus Myocutaneous)
  • Lat Flap (Latissimus)
  • DIEP (Deep Inferior Epigastric Perforator)
  • GAP (Gluteal Artery Perforator)

The surgical transfer of skin, muscle, and fat from one part of the body to the breast area allows for use of your own body's tissue to restore your breast. There are a number of methods to accomplish this transfer and all are generally referred to as "flaps". Once the tissue is collected, it is then shaped to form a new breast mound. An important consideration for our patients is the effect of the tissue collection at the donor site.

The TRAM flap, developed in the late 1970's, allows for use of excess fat in the lower abdomen to reconstruct the breast. The problem with the TRAM flap is that it removes the muscle of the abdominal wall and almost always requires the use of implanted mesh. The effect of this muscle sacrifice in the abdomen is permanent. The resultant weakness can lead to hernia formation and/or bulging in the abdomen since it has been stripped of its supporting muscle tissue.

The Lat Flap cuts away the largest muscle in the back and uses it to rebuild the breast. This procedure usually requires placement of an implant at the same time to provide adequate volume. Sacrifice of the latissimus muscle produces permanent weakness and an unattractive donor site scar.

The DIEP flap employs skin and fatty tissue in the abdomen to restore the breast. The result in the abdomen is much like a tummy tuck in that the abdominal contour is often improved significantly as well. In contrast to the TRAM flap, the DIEP procedure does not sacrifice the muscles of the abdominal wall. This preserves the abdominal strength and avoids the need for implanted mesh.

The GAP flap procedure allows for reconstruction using your own body's tissue when there is inadequate abdominal fat to restore your breast to its proper size and shape. For the woman who is thin or athletic, the breast may be reconstructed with tissue borrowed from the gluteal area. Skin and fatty tissue are collected from the buttocks/hip region without sacrificing underlying muscles. As with the DIEP procedure, the tissue is then sculpted into the new breast mound.

The DIEP and GAP allow for creation of a breast that is warm and living and is your's for life. These procedures allow for creation of a breast that is warm and living and once healed, yours for life. The preservation of muscle tissue and associated function, while still providing restoration with living tissue, represents a significant advancement in breast reconstruction.

With over 15 years of combined experience and thousands of successful breast reconstructions, our Center has pioneered efforts to refine these techniques into methods that now represents the state-of-the art choice in breast reconstruction.