![Page 1: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/1.jpg)
Nipple Sparing Mastectomy:Lessons Learned
Kandace McGuire, MDUniversity Of Pittsburgh
![Page 2: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/2.jpg)
Evolution of Mastectomy
Ancient Egypt 600 B.C.No
Treatment
Hippocrates 400 B.C. Hasten Death
Leonides1st century
A.D.First
Operative Treatment
Gallen 2nd
century A.D.First
Surgical Cure
Heister 18th century Guillotine
mastectomyPetit Radical
mastectomy
Halsted 1880’s
Radical Mastectomy
1970’sModified Radical
Mastectomy
1990’sSkin Sparing Mastectomy
![Page 3: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/3.jpg)
Question
• If all other skin can be maintained, why not the skin of the nipple/areola?
![Page 4: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/4.jpg)
Nipple Sparing Mastectomy
• Background• Classic Inclusion Criteria• Surgical Approach• Special Situations• The Magee Experience
![Page 5: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/5.jpg)
BACKGROUND
![Page 6: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/6.jpg)
Background
• Hartmann – Prophylactic Mastectomy• 575 “subcutaneous mastectomy”• 64 total mastectomy• 7 (1.2%) cancer occurrence, none in NAC
• Sacchini – 192 NSM• At 98.4 weeks, 4 LR, none in NAC
![Page 7: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/7.jpg)
• Crowe – 149 NSM• 73% for DCIS/IDC• At 164 month f/u ‐ 4 LR, 2 DR, none at NAC• 2.7% complication rate
• Petit – 1001 NSM• ELIOT with thicker tissue preserved behind NAC• 80 week f/u – 1.4% LR, none at NAC• NAC loss ~5%
• Benediktsson & Perbeck – Late 1980s• Inclusion criteria varied, outcome poor
![Page 8: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/8.jpg)
Occult Nipple Involvement
Weighted Average = 21% occult nipple involvement
Murthy and Chamberlain Clin Path 2013
![Page 9: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/9.jpg)
Recurrence
Endara et al. Plast Recon Surg 2013
110 (1.8%) 135 (2.2%)
![Page 10: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/10.jpg)
INCLUSİON CRİTERİA
![Page 11: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/11.jpg)
Inclusion Criteria
![Page 12: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/12.jpg)
Poor CandidatesOncologic
Nipple
5cm
![Page 13: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/13.jpg)
Poor CandidatesCosmetic
![Page 14: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/14.jpg)
SURGİCAL APPROACH
![Page 15: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/15.jpg)
Chung & Sacchini: Surgical Oncolog(2008)
Various Nipple Sparing Approaches
a. Nipple‐sparing omega incision b. Transareolar, perinipple incision with lateral extension. c. Transareolar, transnipple incision with medial and lateral extensions. d. Inferior‐lateral mammary crease incision.
![Page 16: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/16.jpg)
Inframammary Approach
5 cm13 cm
![Page 17: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/17.jpg)
![Page 18: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/18.jpg)
![Page 19: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/19.jpg)
Sentinel Node Biopsy
![Page 20: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/20.jpg)
Retroareolar Biopsy
![Page 21: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/21.jpg)
Scissor Dissection
![Page 22: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/22.jpg)
Cautery Dissection
![Page 23: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/23.jpg)
Dilator Dissection
Boneti et al. JACS 2011
![Page 24: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/24.jpg)
Endoscopic “Window” Approach
Ohno et al. Breast Cancer 2011
![Page 25: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/25.jpg)
Video Endoscopic Approach
Tukenmez et al. J Lap Adv Surg Tech. 2014
![Page 26: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/26.jpg)
SPECİAL SİTUATİONS
![Page 27: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/27.jpg)
Special Situations‐ Radiation
Spear et al. Plast Recon Surg 2014
![Page 28: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/28.jpg)
Special Situations ‐ Radiation
Spear et al. Plast Recon Surg 2014
![Page 29: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/29.jpg)
Special Situations – Prior Reduction Mammoplasty
Alperovich et al. Plast Recon Surg 2013
![Page 30: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/30.jpg)
Special Situations – Prior AugmentationNo History of Prior Breast Implant
History of Prior Augmentation Mammoplasty
OR 95% CI P‐value
Hematoma 3 (3%) 1 (2%) .76 0.01‐9.75 1.0
Infection requiring oral antibiotics
13 (11%) 6 (12%) 2.99 0.71‐12.94 0.091
Infection requiring IV antibiotics
10 (9%) 5 (10%) 1.16 0.29‐3.99 0.775
Infection requiring unplanned procedure
6 (5%) 1 (2%) .37 0.01‐3.19 0.677
Wound breakdown 8 (7%) 2 (4%) 0.56 0.06‐2.94 0.725
Superficial nipple necrosis 5 (4%) 0 (0%) 0 0‐1.73 0.324
Partial nipple/areolar necrosis
2 (2%) 1 (2%) 1.94 0.05‐73.8 0.360
Complete nipple/areolarnecrosis
5 (4%) 0 (0%) 0 0‐1.73 0.324
Minor skin flap necrosis 3 (3%) 0 (0%) 0 0‐2.94 0.554
Major skin flap necrosis 6 (5%) 2 (4%) 0.76 0.07‐4.42 1.0
Expander/Implant exposure 6 (5%) 1 (2%) 0.37 0.01‐3.19 0.677
Expander/Implant loss 7 (6%) 5 (10%) 1.71 0.40‐6.60 0.515
Sbitany et al. Plas Recon Surg 2014
![Page 31: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/31.jpg)
Special Situations – Prior Augmentation
Courtesy of Scott Spear, MD
![Page 32: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/32.jpg)
Special Situations ‐ SPY
Wapnir et al. ASO 2014
![Page 33: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/33.jpg)
Special Situations ‐ SPY
Wapnir et al. ASO 2014
![Page 34: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/34.jpg)
Special Situations ‐ SPY
Wapnir et al. ASO 2014
![Page 35: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/35.jpg)
Special Situations – Straight to Implant Reconstruction
Munhoz et al. Breast Cancer Res Treat 2013
![Page 36: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/36.jpg)
Straight to Implant Reconstruction
![Page 37: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/37.jpg)
THE MAGEE EXPERİENCE
![Page 38: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/38.jpg)
The Magee Experience
• 2009 – Current• 124 patients, 227 mastectomies (93 bilateral)• 72% (90/124) prophylactic• 40% (49/124) invasive ductal carcinoma• 7% (8/124) invasive lobular carcinoma• 20% (25/124) ductal carcinoma in situ (DCIS)
![Page 39: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/39.jpg)
The Magee Experience
• Mean follow up 23 months
• 30% (37/124) partial necrosis NAC
• 5% (6/124) full necrosis NAC
• 3% (4/124) nipple involvement
• 1.5% (2/124) recurrence/occurrence
![Page 40: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/40.jpg)
The Magee Experience
• 20% (24/124) s/p neoadjuvant chemotherapy
• 6% (7/124) radiation
![Page 41: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/41.jpg)
![Page 42: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/42.jpg)
DIEP Flap
Implant
![Page 43: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/43.jpg)
![Page 44: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/44.jpg)
TissueExpander
To
ImplantReconstruction
![Page 45: Nipple Sparing Mastectomy: Lessons Learnedfile.lookus.net/amhd/Dr.Kandace McGuire-Nipple Sparing... · 2014. 12. 1. · Special Situations –Prior Augmentation No History of Prior](https://reader033.vdocuments.us/reader033/viewer/2022053122/60a980f21cda8867d16da2d5/html5/thumbnails/45.jpg)
Thank You!!!