INTRODUCTION
By restoring body image after mastectomy,
breast reconstruction improves the overall selfesteem,
satisfaction, sexuality, and quality of life
after surgery. Also, it has proofed to alleviate the
post mastectomy depression and anxiety [1-5].
415
Breast reconstruction became a dynamic continually
progressing group of procedures. These
procedures are aiming to provide the patients after
mastectomy more symmetrical and an aesthetically
pleasing recreated breast in the cases which are
fulfilling multiple basic oncologic goals. The reconstruction
must not impede the oncological safety
or cause a delay in detection of local recurrence
or adjuvant cancer management [6-9].
Autogenous, non-autogenous and combined
modalities have been used in breast reconstruction
with dramatic improvement over the last decades.
By reconstruction with autogenous tissues, it is
easier to achieve symmetry without other breast
modifications. Also, the autogenous reconstruction
has its own indications in multiple situations,
including ptotic contralateral breast, previous radiation
or previous failed reconstruction by implants
[6,10,11,12].
The latissimus dorsi flap was used in breast
reconstruction either with or without implants. It
presents a common source for autogenous breast
reconstruction with the previously mentioned advantages
and, in selected cases, it provides a good
reconstruction option [13].
Changing the management concepts in breast
cancer has motivated the breast reconstruction
surgeons to follow more developed techniques
seeking more aesthetic outcome and less complications.
With growing the popularity of skin -sparing
mastectomy, the glandular tissue and nipple areola
complex are removed while the breast envelope is
maintained which enhances the reconstruction
greatly. The preservation of intermammary crease,
inframammary fold and breast envelope keeps the
breast anatomical cornerstones. Hence, it helps the
plastic surgeon to achieve more natural results
with preservation of these complicated anatomical
structures [9,14].
Several studies have concerned with the risk
of local recurrence in skin sparing mastectomy and
concluded to have a comparable risk with modified
radical mastectomy i.e. 5.8% in early stages (stage
one and two) [15] However, there is an increased
risk of local recurrences i.e. 31% in stage III and
more advanced cases [15,16].
Further modification has occurred in nipplesparing
mastectomy with preservation of nippleareola
complex with the breast skin envelope and
removal of the glandular tissue [14]. This technique
has a significant concern of nipple necrosis that
may exceed 10% which is assumed to be related
to the site of incision. Also, this technique has the
risk of local recurrence which occurs usually in
multicenteric lesions and subareolar tumours.
[17,18,19]. However, in one study, the local recurrences
with nipple sparing technique were three
cases in 123 cases none of them were in nippleareola
complex [18]. Nonetheless, it is a promising
technique with high over all patient satisfaction
[18] Also, longer follow-up periods and larger sample
size reported low recurrence risks [20,21].
The patient with peripheral lesions not less than
2cm from the areolar edge and the lesion is small
and unicenteric can usually be offered this option.
Intra operative frozen section examination is preferred
to roll out occult malignant cells in the
nipple areola complex. Also, the patient should be
informed that there is still lack of high quality data
of the oncologic safety of the nipple sparing mastectomy.
The patient also should be consented that
the nipple areola complex may be insensate, has
a post-operative necrosis or be scarified intraoperatively
if the tumour found proximal to it [21].
Although breast reconstruction can change the
life style of the patient, it has its associated risk
and complications which are continually studied
to be minimized and to enhance the surgery of
breast reconstruction [10].
The aim of the current study is to evaluate the
surgical outcomes of the immediate breast reconstruction
by latissimus dorsi flap in patients after
nipple sparing mastectomy regarding the aesthetic
results, post-operative complications and patient
satisfaction.
PATIENTS AND METHODS
Eight consecutive patients having invasive
breast cancer (7 patient have invasive duct carci-
416 Vol. 42, No. 2 /Post Nipple-Sparing Mastectomy Reconstruction
noma and a patient has invasive lobular carcinoma)
underwent nipple sparing mastectomy. All patients
had immediate breast reconstruction by latissimus
dorsi flap at Zagazig University Hospitals within
three years.
Patient selection:
Eight patients with breast cancer were included
having stage 1 and 2 unicenteric tumors according
to TNM staging; American Joint Committee on
Cancer (AJCC) system. The degree of patient
satisfaction was estimated by a survey (poor, fair,
good, and excellent) in post-operative follow-up
visits (range, 13 to 21 months). Written informed
consent for the study inclusion and publication
was obtained from the patients. All these patients
received immediate breast reconstruction using
pedicled latissimus dorssi flap.
Exclusion criteria:
Patients with tumour size more than 2cm.,
multicenteric tumours, subearolar tumours, tumours
with skin involvements or with the tumour to nipple
distance less than 4cm. and patients with breast
size cup D or larger were excluded from the study.
Surgical procedure:
Nipple sparing mastectomy with axillary lymph
node dissection were performed using a lateral
transverse breast incision (3 cases), lateral inframammary
incision (3 cases), elliptical excising
of the previous biopsy scar (1 case; Fig. 1a) or
elliptical excising of skin when the tumor was
close to the skin. (1 case). In the breast, careful
dissection in the plane of the superficial layer of
the superficial fascia with preservation of the inframammary
fold should be done. (Fig. 1d).
Through the anterior approach, the identification
of the anterior part of the latissimus dorsi muscle
and the thoracodorsal vessels was performed after
completion of NSM. Afterwards, the latissimus
dorsi flap has been harvested on thoracodorsal
neurovascular pedicle after the patient was turned
to the lateral decubitus position, and skin incision
was made within the posterior axillay line (4 cases)
or within the brassière line (4 cases). A subcutaneous
tunnel between the mastectomy defect and the
donor site was done and the flap was elevated and
transferred to the mastectomy defect (Fig. 2d).
Two or more closed suction drains were left at the
LD donor site, mastectomy defect and axilla. These
drains were removed when the daily output became
less than 30cc.
Surgical outcomes in terms of post-operative
complications including hematoma, wound infecEgypt,
J. Plast. Reconstr. Surg., July 2018 417
tion, scarring, dorsal seroma, skin necrosis, back
pain, and aesthetic outcomes such as breast symmetry,
visual difference of bilateral breasts, breast
contour, and nipple cosmoses were assessed by a
panel of three judges (operating surgeon and other
two colleagues of surgeons).
Fig. (1): Nipple sparing mastectomy (A): Incision was replaced by elliptical excision of the large previous biopsy scar, (B):
Nipple sparing mastectomy with glandular resection in the superficial layer of superficial fascia; axillary clearance
was done also through this opening, (C): The mastectomy specimen, (D): Internal view after mastectomy.
Fig. (2): Breast reconstruction with latissimus dorsi flap (A,B,C): Flap harvesting, (D): Flap tunneling, (E): Flap insetting with
fixation to the inframammary line by 2 subcutaneous sutures.
(A) (B) (C)
(E)
(D)
Flap Harvesting
Flap Tunneling Flap Insetting
Flap Tunneling Flap Insetting
(D)
(A) (B) (C)
RESULTS
Eight patients underwent NSM and immediate
purely autogenous breast reconstruction with latissimus
dorsi flap. The mean age of the patients
was 48.4 years (range, 24 to 48). In 7 patients
(85.5%) the pathological results were: Infiltrating
ductal carcinoma and in one patient (12.5%%) the
result was infiltrating lobular carcinoma. The mean
tumor size was 17mm (range, 12 to 20mm). After
a mean follow-up period of 17 months (range, 13
to 21 months), none of the patients developed local
recurrence. Only 1 patient (12.5%) developed an
axillary metastasis, and the overall patient survival
was 100% (Table 1).
418 Vol. 42, No. 2 /Post Nipple-Sparing Mastectomy Reconstruction
Aesthetic outcomes:
The aesthetic outcomes were assessed by a
panel of three judges (operating surgeon and other
two colleagues of surgeons) using a score one to
five. These patients were reviewed according to
the breast aesthetic characters in the form of the
breast shape, size, contour, projection, ptosis,
scarring and visual symmetry. The nipple areola
complex (NAC) was reviewed according to the
transverse level, vertical location and dimensions
of NAC, nipple direction and the nipple necrotic
complications. Other complications of the breast
or donor site were also reported.
Table (1): Study population characteristics.
Age, years
Follow-up, months
Pathological examination:
Infiltrating ductal carcinoma
Infiltrating lobular carcinoma
Tumor size, mm
Stage:
I
IIA
IIB
Local recurrence
Regional Metastasis
Mean 48.4 years
(range, 24 to 48)
Mean 17 months
(range, 13 to 21)
7
1
17mm
(range, 12 to 20mm)
2
3
3
0
1
Cases n (n=8)
Table (2): Post-operative complications.
Hematoma
Wound infection
Necrotic nipple or breast
skin complications
Flap complications
Skin necrosis
Flap loss
Donor site morbidity:
Marked scarring
Seroma
Back pain
000
000
2 (25%)
1 (12.5%)
0
(n=8)
Table (3): Aesthetic outcomes.
Breast Mound:
Shape
Size
Contour
Projection
Ptosis
Scarring
Visual symmetry
Nipple areola complex:
Transverse level
Vertical location
Dimensions symmetry
Nipple direction
Aesthetic scoring
4.3
4,2
4.2
4
3.7
4.6
4.2
3.8
4.4
4.3
4.1
Mean Range 1 to 5
(3 to 5)
(3 to 5)
(4 to 5)
(4 to 5)
(4 to 5)
(4 to 5)
(3 to 5)
(3 to 5)
(4 to 5)
(4 to 5)
(3 to 5)
Post-operative complications:
Post-operative complications including hematoma,
wound infection, flap complications, marked
scarring, dorsal seroma, skin necrosis and back
pain were reported. The incidence of hematoma
0%, wound infection 0%, and skin flap necrosis
0%. Donor site morbidities occurred in 2 cases;
dorsal seroma occurred in one (12.5%) which was
managed with repeated percutaneous aspiration.
Marked scarring occurred in 2 (25%%), and back
pain in 0 (0%).
A survey for estimation of patient satisfaction
was reported for all cases in the follow-up visits.
Six patients have reported an excellent satisfaction
and two patients were unsatisfied. The two poorly
satisfied patients have denoted the causes due to
back incision and relatively smaller breast mound.
Egypt, J. Plast. Reconstr. Surg., July 2018 419
DISCUSSION
Management of breast cancer with advanced
surgical modalities resulted in continuous modifications
in breast reconstruction which became an
integral part in the management of these cases.
Even with these dynamic advancements, sparing
the oncological safety without delaying the adjuvant
cancer management has its priority in the breast
reconstruction. The main aesthetic goals of the
reconstruction are to restore the breast shape,
contour, projection, optimal symmetry, with the
least complications of the breast or donor site [6,7].
In the current study, eight patients underwent
NSM with immediate breast reconstruction by
latissimus dorsi flap. These patients were reviewed
according to the breast aesthetic characters in the
form of the breast shape, size, contour, projection,
ptosis, scarring and visual symmetry. The nipple
areola complex (NAC) was reviewed according to
the transverse level, vertical location and dimensions
of NAC, nipple direction and the nipple
necrotic complications. Other complications of the
breast or donor site were also reported.
Barton and his colleagues [22], concluded that
no grantee of complete malignant cells clearance
with increasing the radicality of the mastectomy
surgery. Residual glandular tissue was reported in
5% of biopsies taken from patients after conventional
modified radical mastectomy. Also, Ho et
al., [23] have reported that the skin flaps contains
malignant cells in up to 23% of cases. The local
recurrence within the skin flap in a large systemic
review in about 3 years follow-up period was 0.9%
and 4.2% in skin sparing mastectomy far lower
than what had reported in unicenteric studies [23].
A debate has been arisen if leaving the nipple
areola complex may result in adding other site for
local tumour recurrence. In a study included 934
patients operated for nipple sparing mastectomy,
the local recurrence in nipple areola complex were
0.8% in 3.5% detected recurrences in breast invasive
duct carcinoma and 2.9% recurrence rate in
4.9% of cases with intra epithelial breast cancers
within fifteen months follow-up period [25]. In
2013, Sakurai and his coauthors in a comparable
study did not found any significant difference in
disease free survival or the overall survival between
patients of NSM and the conventional mastectomy
[26].With this comparable oncological safety, the
sparing of these important structures could be
achievable. So, in nipple sparing mastectomy with
preservation of the breast envelope, inframammary
fold and nipple areola complex, the breast reconstruction
acquires a great cosmetic opportunity.
The tumour size in this study were less than 2
cm. Although the tumour size has been the most
important factor in selection of the patients who
are candidates for NSM, Agarwal et al., [27] reported
increasing incidences in the studies of sizes larger
than 2cm with increasing confidence of the technique.
Furthermore, Leclere et al., [28] used NSM
Fig. (3): Before and after reconstruction views of 36 years old patient with infiltrating duct carcinoma, (A): Pre-operative view,
(B): Post-operative view with the island of skin of myocutaneous latissimus dorsi flap to compensate the excised skin
around the previous biopsy scar, (C): Anterolateral view with the donor site scar, (D,E): Right and left anterolateral
view.
(A) (B)
(C) (D) (E)
technique for 18 in 42 cases with more than 3cm
tumour size with 5.3% local recurrence rate.
The distance between the tumour to nipple in
the inclusion critera of the present study was at
least 4cm. In consistence with the current study,
Chattopadhyay et al., [29] in 2014 reported 0%
local recurrence rate in NSM patients when the
tumour to nipple median distance was 3.8cm. In
the other hand, Fortunato et al., [30] found less
than 1% recurrence rate within 26 months followup
periods in series of cases with 65% of tumour
to nipple distances were less than one cm. The
result of Fortunato et al., suggested that the previous
guidelines regarding that the tumour to nipple
distance must exceed 2cm should be reviewed.
Other selection parameters were suggested to be
used for careful patient selection in NSM patients
like pre-operative MRI imaging [31] or intraoperative
retroareolar frozen section [17] study.
Subareolar tumours were an excluded from the
current study which is consistent with a study by
Eisenberg and his colleagues [32] as they confirmed
that centrally located breast cancers have significant
nipple margin involvement and this location is
associated by NAC malignant cells involvement
in 40% of cases. The tumour location in the present
study was generally evaluated by clinical examination
but MRI imaging were needed twice in
doubtful cases. In consistency, Moon et al., [31]
has reported a positive correlation between NAC
enhancement and malignant invasion with high
sensitivity and specificity.
In the current study, the benefits of immediate
breast reconstruction have been revealed in minimizing
the hospital admissions and stages of surgeries
as well relieving the postmastectomy psychological
trauma. This conclusion was reported
by many authors [32].
The breast reconstruction using autogenous
tissue has its own indications in multiple situations,
including [10] ptotic contralateral breast, previous
radiation or previous failed reconstruction by implants
[6]. The latissimus dorsi flap was used in
breast reconstruction either with or without implants.
It presents a common source for autogenous
breast reconstruction with the previously mentioned
advantages and, in selected cases, it provides a
good reconstruction option [6,11,12].
The flap has been reported as a good option in
reconstructing patients with failed previous reconstruction
or previous abdominal surgeries [6,12].
In the other hand, the volume of the reconstructed
breast created from the flap only is relatively
420 Vol. 42, No. 2 /Post Nipple-Sparing Mastectomy Reconstruction
small which should be considered. So, achieving
symmetrical results usually occurs either by selection
of patients with suitable breast mound, using
the flap with autogenous augmenting tissues or to
use the flap associated with an implant. In the
current study, the patients included are with cup
A, B or C breast sizes. Also, near total flap use
and inclusion of the latissimus dorsi muscle overlying
fat to obtain an extra volume were performed.
Some studies reported the use of the latissimus
dorsi overlying fat in the series of McCrew and
Papp [34]. Also, Denewer [13] created the extra
volume by using the fat overlying the serrstus
anterior muscle as a pedicled flap.
The purely autogenous reconstructions in the
present study avoided the complications associated
with using implants such as capsular contracture,
delayed healing, implant malposition, implant
extrusion or infection. In the other hand, the latissimus
dorsi breast reconstruction still carried the
risk of donor site morbidities, seroma formation
(47%-96%), back contour irregularity and shoulder
weakness which reported in the study of Sigurdson
et al., [36] In the current study, the incidence of
seroma was significantly lower; 25% without detection
of noticed shoulder function disabilities.
An important drawback of the procedure in the
present study was the noticed back scar which was
alleviated to some extent by orienting the incision
transversely in the brassiere line, careful subcuticular
skin closure and post-operative wound care.
Rawlani et al., [33] reported in their study that
a higher rate of nipple necrosis was associated with
the periareolar incision than using the lateral or
inframammary incision in NSM. Regarding the
current study, medial breast incisions were avoided
instead lateral or lateral inframammary incision
were used in NSM. Also, Crowe et al., [37] supported
this attitude and reported that the medial incisions
may compromise the nipple blood supply. In two
cases, when a previous biopsy was taken before
with large incision, an ellipse of the skin surrounding
the previous scar were excised and used for
NSM and the defect is replaced by a skin paddle
of the back as a myocutaneous latissimus dorsi flap
with good colour match. No necrotic complications
were reports in the cases of the present study this
may be due to the use of these incisions and not
the periareolar and the relatively small breast
mounds included in the study. In consistence with
this concept Colwell and his colleagues have linked
increasing nipple necrosis incidence with obesity
or with a large breast volume [38].
Egypt, J. Plast. Reconstr. Surg., July 2018 421
Regarding different studies, the necrotic complications
still have relatively low rates ranging
from 3.5% in total nipple necrosis to 12.1% in
partial nipple necrosis and NSM is still a useful
technique [38-41]. Furthermore, Alperovich et al.,
[42] have argued that the necrotic complications
with NSM has not increased with subsequent radiotherapy
if needed.
In terms of nipple sensation, six cases in the
current study have been preserved. Nahabedian
and Tsangaris [43] reported that NSM has maintained
sensation in 6 of 14 nipples (42.9%). The
nerve supply to the nipple from the lateral T4 is
scarified in most mastectomies. However, a part
of NAC innervation comes from medial T3 which
is responsible for nipple sensation preservations
in these cases [44]. The higher incidence of preserving
nipple sensibility in the present study may be
due to the selection lateral and lateral inframammary
incisions and avoidance of medial incisions
with preservation of these innervation.
In the present study, After NSM and immediate
latissimus dorsi breast reconstruction, a survey for
estimation of patient satisfaction was reported for
all cases in the follow-up visits. Six patients have
reported an excellent satisfaction and two patients
were unsatisfied. The two poorly satisfied patients
have denoted the causes due to back incision and
relatively smaller breast mound. This result was
comparable with the result of Nahabedian and
Tsangaris [43] who obtained patient satisfaction in
11 of 14 patients (78.6%).
Conclusion and recommendations:
Following nipple sparing mastectomy, purely
autogenous immediate breast reconstruction by
latissimus dorsi flap is a valuable reconstructing
technique in selected type of patients. It has low
incidence of complications, considerable aesthetic
outcomes with high patient satisfaction relieving
the psychological postmastectomy trauma. Further
researches in terms of more volume enlargement
and minimizing donor scar effects could preserve
the privileges of latissimus dorsi breast reconstruction
in nipple sparing mastectomy patients, maximize
its use in breast reconstruction and expand
the spectrum to a larger group of patients.
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