Experience with postmastectomy radiation therapy in nipple-sparing mastectomy

Abstract

Over recent years, nipple-sparing mastectomy (NSM) has grown in popularity, as an oncologically safe procedure with improved aesthetic outcomes for patients. Breast reconstruction following NSM carries distinct challenges, especially with the addition of postmastectomy radiation therapy (PMRT). Following aggressive removal of nipple parenchyma, the thinned out nipple-areola complex (NAC) is especially susceptible to the effects of PMRT. The author has reported an overall explantation rate of 17.7 % for prosthetic reconstruction following NSM and PMRT. This is a reduction in prosthetic device failure, which was previously reported in other studies at rates up to 40 % following skin sparing mastectomy and PMRT. Reasons for these decreased complication rates include the use of acellular dermal matrices, use of periareolar incisions over inframammary incisions, and wait times of at least 6 months following PMRT completion prior to expander/implant exchange. Patient satisfaction with prosthetic reconstruction following NSM and PMRT remains variable. Aesthetics can be improved by suturing of the NAC in place at time of mastectomy, to prevent migration. It is now know that axillary lymph node dissection (ALND) carries a significant increased risk of reconstructive failure. Thus, these patients may be encouraged to undergo autologous reconstruction. Autologous reconstruction can be safely performed following NSM, either in immediate fashion, or with tissue expander placement and second stage exchange for autologous flap.