Il trattamento delle complicanze in chirurgia senologica ricostruttiva Tecniche per la prevenzione delle complicanze nelle mastectomie conservative Dr. Christian Rizzetto UOC Chirurgia Senologica - Breast Unit Direttore Dott. Paolo Burelli
A historic perspective Hasteld WS 1852-1922 Mastectomia Quart SSM e NSM 1900 2000 mammografia CT neoadiuvante Screening RM IORT BLS
Size of the problem At least 25-30% of women with breast cancer is candidate for mastectomy BCS Mastectomy Conservative mastectomy represents the evolution of traditional mastectomy
Conservative Mastectomy s Toth B and Lappert P, Plast Reconstruct Surg 1991 Kroll SS et al, Surg Gynecol Obstet 1991 Verheyden CN, American Society of Plastic Surgeons 1998 Nava MB et al, Plast Reconstr Surg 2006
Nipple sparing mastectomy Removal of the whole gland while preserving skin, NAC, and inframammary fold true breast-conserving mastectomy
GOALS Oncological Radicality NAC preservation Aesthetic Outcome
Nipple-sparing mastectomy Indications Multifocal/multicentric carcinoma (in situ or invasive) High tumor/breast ratio Margin involvement after conservative surgery Relapse after BCT Patient refuses BCT Patient s refusal or impossibility to radiotherapy Difficulty for follow-up after conservative surgery Hereditary neoplastic syndromes (BRCA, others)
Absolute Intraoperative evidence of tumor in sub-areolar tissue conversion to SSM Paget s disease of the nipple consider SSM Nipple retraction consider SSM Skin involvement Inflammatory disease Significant ptosis (NAC ptosis > 8 cm) consider SRM Large breast (> 500 cm3) consider SRM Relative Nipple-sparing mastectomy Contraindications Tumor-NAC distance <2 cm in mammography or MRI; Sub-areolar microcalcifications; Bloody discharge from nipple.
Increasing eligibility for nipple-sparing mastectomy Coopey SB et al. Ann Surg Oncol 2013
Nipple-sparing mastectomy Type of complications Haematoma Infection Minor skin necrosis Major skin and/or NAC necrosis (skin flap viability)
Set AK Ann Plast Surg 2013
Extended systemic antibiotic prophylaxis would decrease infection risk in breast implant surgery Topical antibiotic irrigation would decrease capsular contracture risk Cephalosporin was the most commonly preferred antibiotic regimen Risk factors should be taken into consideration
Nipple-sparing mastectomy Type of complications Haematoma Infection Minor skin necrosis Major skin and/or NAC necrosis (skin flap viability)
SKIN INCISION Does incision Matter?
SKIN INCISION Upper peri-areolar incision with lateral extension. This type of incision is useful when a surgical approach to axilla is required. However, it often results in a lateralization of the NAC, requiring corrective action.
SKIN INCISION Upper-outer radial incision. This type of incision should be preferred because it facilitates access to axilla, glandular excision, and reconstruction time. Moreover, it minimally damages NAC vascularization and scar outcome is usually excellent, except for few cases of slight lateral deviation of NAC.
SKIN INCISION Inframammary incision. Skin incision is carried out at the lateral third of inframammary fold; in this area scar is practically invisible. The surgeon will however find it difficult to perform a complete demolition of the upper quadrants and to carry out axillary surgery, especially in large breasts.
NIPPLE MARGIN ASSESSMENT Need for correct section of subareolar tissue Frozen sections of central core of the NAC (negative false: 4.6%, Vlajcic Z, 2005; 9.2%, Kneubil MC, 2012) Clinical data on predictable NAC involvement do not reach significancy (areola involvement 1%; nipple involvement 10.6%)
Vascular supply of the nipple vascular supply with the nipple Common configuration of blood supply to the nipple-areola complex and intercostal perforator seen on MRI. van Deventer PV et al. Aesthetic Plastic Surgery 2004
FLAP There is not a standard flap thickness Flap thickness varies from patient to patient Dissection occurs along an intra-operatively identifiable anatomical plane
Patient risk factor Skin flap viability Surgical technique
Patient risk factor Effects of smoking Previous scars Previous radiotherapy Diabetes Obesity Severe co-morbidities
Surgical technique Skin flap thickness Tumescent technique Dissection devices cautery scissors harmonic scalpel
Is Oncologic Safety Compatible with a Predictably Viable Mastectomy Skin Flap? 44% 56% Mammary gland is located in the anterior thoracic region, within a splitting of the superficial fascia. Beer GM et al., Cancer, 2002 The anterior lamina (pre-mammary) of the superficial fascia is found in less than 50% of breasts; if present, it is rarely continuous.
Superficially to the anterior lamina, there is a cellulo-adipose layer, whose thickness varies among different patients and, in the same patient, from quadrant to quadrant.
Distance between breast gland and dermis Lack of predictive factors Larson DL et al. Plast Reconstr Surg 2011
Beer GM et al. Cancer 2002 Robertson SA et al. Br J Surg 2014 Considering the aforementioned information, together with the fact that mammary islands can be found externally to the anterior lamina Lobular arrangement within the superficial layer
Minimal distance (arrow) between breast tissue and the overlyng dermis THE DEFINITION OF AN IDEAL ONCOPLASTIC PLANE (along which an oncologically-safe mastectomy should be carried out) IS A REAL CHALLENGE.
Surgical technique Skin flap thickness Tumescent technique Dissection devices cautery scissors harminic scalpel
Prepectoral breast reconstruction with Braxon
The never ending story: Determinants of optimal mastectomy skin flap thickness Whether to use cautery, knife or scissors, whether to make thin or thick flaps or whether to use or not use tumescence all have their supporters and detractors
Conclusions The thickness of subcutaneous layer is variable and is difficult to predict before surgery A single specific universal thickness for mastectomy skin flaps cannot be recommended currently The surgeon must use skill and judgement to identify the oncoplastic plane Achieving clear resectin margins remains an important surgical goal to reduce the risk of local relapse Patient risk factors and surgical technique play a role both in optimizing oncological outcomes and in reducing the risk of local complications
UOC Chirurgia Senologica - Breast Unit Aulss 2 Marca Trevigiana Direttore Dott. P. Burelli Dott.ssa M. Baldessin Dott.ssa F. Callegari Dott.ssa B. Gnocato Dott C. Rizzetto
Matter of high and increasing interest: growing request for NSM (media) Highly appreciated by patients Careful evaluation of cases Learning curve A whole knowledge of implants and devices is necessary Complication risk Precise indications still undefined High cost of materials Need of further studies
Nipple-Areola Complex Management Ductal tissue within nipple Subareolar/ nipple duct margin Superficial retroareolar tissue