Nguyên Lý Và Kỹ Thuật Trong Phẫu Thuật Ung Thư Vú Tạo Hình

Skin-Sparing Mastectomy
181
Figure 10.6.
This type of incision is favored in patients who have ptotic breasts with
excess skin and who are planned for tissue transfer reconstruction. The excess skin of
the breast may be taken around the areola with or without a lateral extension in the
form of a J-mastopexy.
Figure 10.7.
“Fish-tail” or “tennis racquet” incisions are very helpful when planning
resection of the skin or prior lumpectomy scars. The triangular extension is centered
around the area of skin to be excised. The triangular extension may be aligned toward
any quadrant of the breast as seen in Figure 10.8.

182
Principles and Techniques in Oncoplastic Breast Cancer Surgery
degree of ptosis of the breast, the diameter of the areola, prior lumpectomy
scars, and type of reconstruction (autologous versus implants).
For patients with planned autologous tissue transfer, we prefer the
circumareolar incision because it results in minimal scarring with opti-
mal cosmetic results (Figure 10.9). When planning reconstruction with an
expander, we have resorted to an elliptical incision because circumareolar
incisions are usually converted to elliptical for closure. Regardless of the
Figure 10.8.
“Fish tail” with triangular extension to the upper outer quadrant.
Figure 10.9.
This patient underwent a skin-sparing total mastectomy through a cir-
cumareolar incision with bilateral extension.

Skin-Sparing Mastectomy
183
type of incision used, however, the primary goal remains complete oncologic
resection. Therefore, additional skin removal may be necessary to achieve
clear anterior margins.
10.3 Mastectomy
The same mastectomy principles used in a non-SSM apply to SSM. When
the circumareolar incision is used, however, the procedure can become
challenging in patients with a small NAC and rigid skin; we have frequently
resorted to lateral/medial extensions in these cases. Early, in the experience
of breast surgeons, we recommend extending the lateral incisions without
skin resection to achieve a complete extirpation of the breast. The patient
is placed supine with the arm extended on a padded arm board. The arm
should be prepped and draped separately to allow free rotation. After the
skin incision is completed, the subcutaneous planes are exposed. Hemosta-
sis should be maintained at all times during the procedure. Dissection may
be performed with electrocautery or by sharp dissection with scalpel or
curved scissors. If sharp dissection is undertaken, the tumescent mastec-
tomy technique significantly reduces bleeding. This procedure refers to the
subcutaneous injection of a liquid mixture of salts and small amounts of
two drugs: lidocaine to numb the area, and epinephrine to narrow the blood
vessels and reduce bleeding. We use a solution which consists of 1,000 ml
of Ringers lactate with 20 cc of 1% lidocaine with epinephrine 1:100,000.
Retractors, clamps, or skin hooks are used to elevate the skin edges. We
strongly recommend following the superficial fascial plane while elevating
the skin flaps (see Chapter 1). Dissection in that plane is bloodless and
preserves the integrity of the blood supply to the overlying skin. Adhering
to the superficial fascial plane is a crucial factor to the survival of the
skin flaps and maximal removal of breast tissue. We avoid adhering to
a specific thickness when elevating the skin flaps as there is significant
variation between patients. Furthermore, the skin flaps in the same patient
gradually increase in thickness while moving away from the NAC. Although
some have doubted the presence of a superficial fascial plane and have not
been able to identify it as a histologic entity,9 we feel that in a significant
number of patients, the subcutaneous plane is well visualized when raising
the flaps. In some patients, however, we have found some difficulty in clearly
identifying that “bloodless” plane.
To identify the plane of dissection, the assistant holds upward tension
on the skin flaps while the surgeon uses countertraction on the breast
parenchyma. Excessive bleeding indicates that the dissection is not in the
correct anatomic plane that separates the superficial fascia from the sub-
dermal vascular plexus. Special caution should be exercised to preserve
the principal blood vessels of the skin, and a profound knowledge of the

184
Principles and Techniques in Oncoplastic Breast Cancer Surgery
vascular anatomy of the skin overlying the breast (as summarized in the
introduction of this chapter) is mandatory for the success of the SSM pro-
cedure. The skin flaps extend superiorly to the clavicle, medially to the
sternal edge, and laterally to the latissimus dorsi. The lower skin flap is
then developed to the inframammary crease. There have been reports in
the literature describing the importance of maintaining the IMF. We have
routinely used the same technique for SSM and conventional mastectomy.
The IMF can be recreated by imbricating the skin to the chest wall during
the reconstructive procedure.
In non-SSM, we have traditionally started with the upper flap and
addressed the lower flap later. In SSM, however, our experience consists of
progressively raising the flaps circumferentially. We recommend using deep
Richardson retractors or, preferably, lighted 90-degree retractors.
The next step is the removal of the breast. We start superiorly and
progress downward along the pectoralis muscle fibers. We have routinely
included the pectoralis fascia based on the anatomic observation of breast
tissue extending to the fascia through Cooper’s ligament. In prophylactic
mastectomy, however, we may keep the pectoralis fascia intact and adhere
to the retromammary space. Many small arteries perforate the pectoralis
muscle and contribute to the circulation of the breast; we recommend
careful cauterization of these vessels. Of note, however, are the medial
parasternal perforators, particularly those that arise from the second or
third intercostal spaces: the internal mammary perforators. These vessels
are relatively larger in caliber, and we recommend taking the time to lig-
ate or clip these vessels. The dissection is extended to the lateral aspect of
the pectoralis major and serratus muscles, and the breast is removed. We
have found that elevating the skin offthe axillary breast tail to be quite
difficult through a circumareolar incision. We address the axillary tail after
having raised the superior, medial, and inferior flaps, and after separating
the breast offof the muscle. The breast is exteriorized through the nip-
ple areola defect and used for traction. This technical maneuver facilitates
raising the skin flaps of the axillary tail and dissecting the axilla. We rou-
tinely apply a suture in the axillary tail for specimen orientation prior to
submission for pathologic evaluation.
10.4 Axillary Staging
Extensions are usually not necessary for adequate access to the sentinel
lymph nodes. All blue and/or “hot” lymph nodes are removed, along
with any suspicious, palpable nodes. For complete axillary lymph node
dissection, the breast envelope is reflected laterally to gain access to the
axilla. If access is difficult, “tennis racquet”, “fish-tail”, or separate axillary

Skin-Sparing Mastectomy
185
incisions allow easier exposure. Typically, the reduction incision and mod-
ified ellipse allow good access to the axilla without extensions. Axillary
lymph node dissection clears levels I and II. Complete axillary clearance
that includes levels I, II, and III is only indicated when the surgeon palpates
suspicious nodes in the apex of the axilla. When relying on blue dye to iden-
tify the sentinel node, we strongly recommend a separate axillary incision.
10.5 Reconstruction
Reconstruction can be performed with an implant or with a tissue trans-
fer, preferably with autologous tissue from the abdominal wall (TRAM
flap/DIEP flap) or back (latissimus flap). Typically, with an implant recon-
struction, a tissue expander is placed at the time of the SSM under the pec-
toralis muscle. The tissue expander is injected with saline over few weeks to
stretch the subpectoral pocket. The permanent implant is placed during a
second procedure. In patients who are having an autologous reconstruction,
we have exerted every effort to limit our incision to around the areola. The
plastic surgeon then limits the skin paddle of the flap to the NAC defect
Figure 10.10.
Circumareolar incision. The abdominal skin paddle is limited to the site
of the NAC.

186
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 10.11.
Flap skin paddle used to reconstruct the nipple and tattooed as an areola.
(Figure 10.10). The myocutaneous flap skin paddle can later be used to
reconstruct the nipple and tattooed as an areola. In our experience this
technique has led to excellent cosmetic results (Figure 10.11).
10.6 Safety
Safety of the SSM technique can be defined in 3 ways. The first is the
risk of short-term complications which may delay adjuvant therapy. The
second is the risk of incompleteness of mastectomy due to limited expo-
sure compared with the non-SSM technique, hence leaving residual breast
tissue behind that may be prone for future malignant transformation, par-
ticularly in mutation carriers and high-risk patients. The third is the risk
of incompleteness of tumor removal in the skin envelope, resulting in posi-
tive margins. All of these factors could, in theory, jeopardize the oncologic
outcome in terms of local recurrence.
10.7 Postoperative Complications
Aside from reconstructive procedure complications, the principal postoper-
ative concern is skin-flap ischemia. This occurs in 5% to 15% of patients and
ranges from simple epidermolysis to full-thickness skin flap necrosis.10−12
The resulting exposure of muscle or implant may cause skin retractions,

Skin-Sparing Mastectomy
187
infection, or even loss of the implant. The latter has been reported in
up to 18% of patients.4,11−13 Therefore every effort should be made to
preserve the main blood supply to the skin of the female breast. Other
complications include hematoma and seroma, which occur in the initial
postoperative period.14
A recent study assessed potential risk factors for postoperative compli-
cations and found that the Wise-pattern and the “tennis racquet” incision
had significantly higher rates of wound dehiscence when compared with the
circumareolar incision (p = 0.025 and p = 0.098, respectively).15 There was
no significant difference between diathermy or blade dissection techniques,
and no higher risk associated with the use of the tumescent mastectomy
technique. However, recent studies have shown higher wound complica-
tion with the tumescent technique in patients undergoing mastectomy and
immediate reconstruction.16
10.8 Completeness of Mastectomy
The goal in all mastectomies is to create skin flaps that are thin enough to
remove all breast tissue and thick enough to provide sufficient blood supply.
The amount of breast tissue left behind, however, is similar in both SSM
and non-SSM techniques.9 In patients undergoing SSM, residual glandular
tissue is found in more than one-half of the patients in the IMF, but this
accounts for only 0.02% of total breast tissue.17 Hence there is no evidence
in the literature suggesting that SSM is less complete than non-SSM.
10.9 Completeness of Tumor Removal and Local
Recurrence Rates
The main oncologic concern in SSM relates to the possibility of leaving
residual tumor within the skin envelope, which may manifest later as local
recurrence. Ho et al.18 performed a histological analysis on the skin and
10 mm of the subcutaneous tissue of 30 total mastectomy specimens by the
step-serial–sectioning technique. They found that the incidence of skin-flap
involvement outside the NAC was 23% (7 of 30). The significant parameters
related to skin-flap involvement were skin tethering (75% versus 15%,
p < 0.05), pathologic tumor size (p < 0.03), and perineural infiltration
(63% versus 9%, p < 0.01). The authors concluded that it would be onco-
logically safe to perform SSM in T1 and T2 tumors, and preserve the skin
overlying the tumor, if there is no skin tethering.
Even though the previously cited study provided indirect evidence of
the appropriateness of SSM, the oncologic safety of SSM is ultimately

188
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Table 10.1.
Local recurrence rates after skin-sparing mastectomy versus
non-skin–sparing mastectomy.
Study
Median
follow-up
(months)
N
(SSM)
LR in
SSM
(%)
N
(non-SSM)
LR in
non-SSM
(%)
Carlson et al.6
42
327
4.8
188
9.5
Kroll et al.25
72
104
6.7
27
7.4
Slavin et al.4
45
51
2.0
188
9.5
Simmons et al.5
60
77
3.9
154
3.3
Rivadeneira et al.29
49
71
5.6
127
3.9
Greenway et al.27
49
225
3.8
1022
3.9
Howard et al.28
59
34
0
395
3.8
Gerber et al.35
101
48
10.4
130
11.5
determined by the long-term rates of local recurrence. There are no
randomized clinical trials evaluating the safety of SSM to date. In addi-
tion, many of the observational studies on SSM reported a mean follow-up
of 8–24 months, which seems to be too short for evaluation of oncologic
safety.14,19−25 The vast majority of local recurrence following a total mas-
tectomy occurs within 24 months, however. Multiple observational studies
with a sufficient follow-up of longer than 24 months demonstrated low local
recurrence rates in patients undergoing SSM for breast cancer.4−6,26−35
They ranged from 0% to 10.4%, and were similar for the SSM and the
non-SSM groups (Table 10.1). Since the majority of these studies included
T1-2 and stage 0-II disease, multicentric cancer, ductal carcinoma in situ,
and risk-reduction surgery, it can be concluded that SSM is safe in these
patients. Increasing clinical experience, however, suggests that SSM can
be reliably performed in larger tumors as long as there is sufficient dis-
tance between the tumor and the skin in the absence of skin changes. This
includes large tumors which are downstaged by neoadjuvant CTX. Hence,
the only absolute contraindications for SSM in today’s surgical practice are
inflammatory breast cancer and direct tumor involvement of the skin.
10.10 Cosmesis
SSM preserves the breast envelope and facilitates immediate breast
reconstruction.15 Gerber et al. have shown that the aesthetic results
are better compared with secondary breast reconstruction, and that the
improved aesthetic result translates to greater patient and surgeon satis-
faction after SSM compared to modified radical mastectomy.36,37

Skin-Sparing Mastectomy
189
Over time, the reconstructed tissue regains the shape of the orig-
inal breast envelope, allowing symmetry and ptosis to be achieved.38
SSM prevents transverse scars associated with conventional non-SSM.
(Figures 10.10–10.11). In patients who undergo circumareolar incision and
tissue reconstruction, the cutaneous part of the flap is only visible as an
island for the NAC, thereby preventing contrast between the pale abdom-
inal skin and the breast envelope.8,39 This provides an ideal color and tex-
ture to the breast skin.14 The best cosmetic outcomes are found in women
who have not had prior RT and those who are unlikely to need adjuvant
RT, even though RT does not represent a contraindication for SSM and
immediate breast reconstruction.33
References
1. Toth BA, Lappert P. (1991) Modified skin incisions for mastectomy: The
need for plastic surgical input in preoperative planning. Plast Reconstr Surg
87(6):1048–1053.
2. Bleicher RJ, Hansen NM, Giuliano AE. (2003) Skin-sparing mastectomy
specialty bias and worldwide lack of consensus. Cancer 98(11):2316–2321.
3. Salmon M. Les art`eres de la glande mammaire. (1939) Ann Anat Pathol
16:477–500.
4. Slavin SA, Schnitt SJ, Duda RB, et al. (1998) Skin-sparing mastectomy and
immediate reconstruction: Oncologic risks and aesthetic results in patients
with early-stage breast cancer. Plast Reconstr Surg 102(1):49–62.
5. Simmons RM, Fish SK, Gayle L, et al. (1999) Local and distant recurrence
rates in skin-sparing mastectomies compared with non-skin-sparing mastec-
tomies. Ann Surg Oncol 6(7):676–681.
6. Carlson GW, Bostwick J, 3rd, Styblo TM, et al. (1997) Skin-sparing
mastectomy.
Oncologic
and
reconstructive
considerations.
Ann
Surg
225(5):570–575; discussion 575–578.
7. Toth BA, Forley BG, Calabria R. (1999) Retrospective study of the
skin-sparing mastectomy in breast reconstruction. Plast Reconstr Surg
104(1):77–84.
8. Hidalgo DA. (1998) Aesthetic refinement in breast reconstruction: Complete
skin-sparing mastectomy with autogenous tissue transfer. Plast Reconstr
Surg 102(1):63–70; discussion 71–72.
9. Barton FE, Jr., English JM, Kingsley WB, et al. (1991) Glandular excision in
total glandular mastectomy and modified radical mastectomy: A comparison.
Plast Reconstr Surg 88(3):389–392; discussion 393–394.
10. SufiPA, Gittos M, Collier DS. (2000) Envelope mastectomy with immediate
reconstruction (EMIR). Eur J Surg Oncol 26(4):367–370.
11. Carlson GW, Losken A, Moore B, et al. (2001) Results of immedi-
ate breast reconstruction after skin-sparing mastectomy. Ann Plast Surg
46(3):222–228.

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
12. Contant CM, van Geel AN, van der Holt B, et al. (2000) Morbidity of
immediate breast reconstruction (IBR) after mastectomy by a subpectorally
placed silicone prosthesis: The adverse effect of radiotherapy. Eur J Surg
Oncol 26(4):344–350.
13. Clough KB, Bourgeois D, Falcou MC, et al. (1996) Immediate breast recon-
struction by prosthesis: A safe technique for extensive intraductal and
microinvasive carcinomas. Ann Surg Oncol 3(2):212–218.
14. Munhoz AM, Aldrighi C, Montag E, et al. (2007) Periareolar skin-
sparing mastectomy and latissimus dorsi flap with biodimensional expander
implant reconstruction: Surgical planning, outcome, and complications. Plast
Reconstr Surg 119(6):1637–1649; discussion 1650–1652.
15. Davies AL, Roblin P, Ross D, Farhadi J. (2010) Factors affecting post-
operative complications following skin sparing mastectomy with immediate
breast reconstruction. The Breast; Epub ahead of print.
16. Seth AK, Hirsch EM, Fine NA, Dumanian GA, Mustoe TA, Galiano RD,
Hansen NM, Kim JY. (2011) Additive risk of tumescent technique in patients
undergoing mastectomy with immediate reconstruction. Ann Surg Oncol
18(11):3041–3046.
17. Carlson GW, Grossl N, Lewis MM, et al. (1996) Preservation of the infra-
mammary fold: What are we leaving behind? Plast Reconstr Surg 98(3):
447–450.
18. Ho CM, Mak CK, Lau Y, et al. (2003) Skin involvement in invasive
breast carcinoma: Safety of skin-sparing mastectomy. Ann Surg Oncol 10(2):
102–107.
19. Margulies AG, Hochberg J, Kepple J, et al. (2005) Total skin-sparing mas-
tectomy without preservation of the nipple-areola complex. Am J Surg
190(6):907–912.
20. Petit JY, Veronesi U, Orecchia R, et al. (2006) Nipple-sparing mastectomy
in association with intra operative radiotherapy (ELIOT): A new type of
mastectomy for breast cancer treatment. Breast Cancer Res Treat 96(1):
47–51.
21. Salhab M, Al Sarakbi W, Joseph A, et al. (2006) Skin-sparing mastectomy
and immediate breast reconstruction: Patient satisfaction and clinical out-
come. Int J Clin Oncol 11(1):51–54.
22. Peyser
PM,
Abel
JA,
Straker
VF,
et
al.
(2000)
Ultra-conservative
skin-sparing ‘keyhole’ mastectomy and immediate breast and areola recon-
struction. Ann R Coll Surg Engl 82(4):227–235.
23. Rashid M, Ilahi I, ur Rehman Sarwar S, et al. (2005) Skin sparing mas-
tectomy and immediate breast reconstruction. J Coll Phys Surg Pak 15(8):
467–471.
24. Psaila A, Pozzi M, Barone Adesi L, et al. (2006) Nipple sparing mastec-
tomy with immediate breast reconstruction: A short term analysis of our
experience. J Exp Clin Cancer Res 25(3):309–312.
25. Wijayanayagam A, Kumar AS, Foster RD, et al. (2008) Optimizing the total
skin-sparing mastectomy. Arch Surg 143(1):38–45; discussion 45.

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26. Kroll SS, Schusterman MA, Tadjalli HE, et al. (1997) Risk of recurrence
after treatment of early breast cancer with skin-sparing mastectomy. Ann
Surg Oncol 4(3):193–197.
27. Greenway RM, Schlossberg L, Dooley WC. (2005) Fifteen-year series of
skin-sparing mastectomy for stage 0 to 2 breast cancer. Am J Surg
190(6):918–922.
28. Howard MA, Polo K, Pusic AL, et al. (2006) Breast cancer local recurrence
after mastectomy and TRAM flap reconstruction: Incidence and treatment
options. Plast Reconstr Surg 117(5):1381–1386.
29. Rivadeneira DE, Simmons RM, Fish SK, et al. (2000) Skin-sparing mas-
tectomy with immediate breast reconstruction: A critical analysis of local
recurrence. Cancer J 6(5):331–335.
30. Medina-Franco H, Vasconez LO, Fix RJ, et al. (2002) Factors associated
with local recurrence after skin-sparing mastectomy and immediate breast
reconstruction for invasive breast cancer. Ann Surg 235(6):814–819.
31. Fersis N, Hoenig A, Relakis K, et al. (2004) Skin-sparing mastectomy and
immediate breast reconstruction: Incidence of recurrence in patients with
invasive breast cancer. Breast 13(6):488–493.
32. Downes KJ, Glatt BS, Kanchwala SK, et al. (2005) Skin-sparing mastectomy
and immediate reconstruction is an acceptable treatment option for patients
with high-risk breast carcinoma. Cancer 103(5):906–913.
33. Patani N, Devalia H, Anderson A, et al. (2008) Oncological safety and patient
satisfaction with skin-sparing mastectomy and immediate breast reconstruc-
tion. Surg Oncol 17(2):97–105.
34. Omranipour R, Bobin JY, Esouyeh M. (2008) Skin Sparing Mastectomy and
Immediate Breast Reconstruction (SSMIR) for early breast cancer: Eight
years single institution experience. World J Surg Oncol 6:43.
35. Gerber B, Krause A, Dieterich M, et al. (2009) The oncological safety
of skin sparing mastectomy with conservation of the nipple-areola com-
plex and autologous reconstruction: An extended follow-up study. Ann Surg
249(3):461–468.
36. Gerber B, Krause A, Kuchenmeister I, et al. (2000) Skin sparing mastectomy
with autologous immediate reconstruction: Oncological risks and aesthetic
results. Zentralbl Gynakol 122(9):476–482.
37. Gerber B, Krause A, Reimer T, et al. (2003) Skin-sparing mastectomy with
conservation of the nipple-areola complex and autologous reconstruction is
an oncologically safe procedure. Ann Surg 238(1):120–127.
38. Sotheran WJ, Rainsbury RM. (2004) Skin-sparing mastectomy in the UK —
A review of current practice. Ann R Coll Surg Engl 86(2):82–86.
39. Bensimon RH, Bergmeyer JM. (1995) Improved aesthetics in breast recon-
struction: Modified mastectomy incision and immediate autologous tissue
reconstruction. Ann Plast Surg 34(3):229–233; discussion 233–235.

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Chapter 11
NIPPLE-SPARING MASTECTOMY
Sunny Mitchell∗and Sheldon Marc Feldman†
∗Women’s Breast Center, Department of Surgery, Tully Health Center,
32 Strawberry Hill Court, Stamford, CT 06902, USA
†Division of Breast Surgical Oncology,
Columbia University Medical Center,
New York City, NY, 10032, USA
11.1 Introduction
Nipple-sparing mastectomy (NSM) entails removing all breast tissue,
including all breast tissue immediately under the nipple areola complex
(NAC), while sparing the skin envelope, including the NAC. This type of
mastectomy, combined with immediate reconstruction, leads to a postop-
erative reconstructed breast, appearing nearly identical to a preoperative
breast (unless a mastopexy is added to decrease ptosis). Benefits include
nipple and areola preservation, and improved overall cosmesis. This is in
direct contrast to the more traditional mastectomy types — modified rad-
ical mastectomy (MRM), total mastectomy (TM), or skin-sparing mastec-
tomy (SSM) — all of which entail removing the NAC with varying amounts
of skin immediately surrounding the NAC. A subcutaneous mastectomy
has been described as a mastectomy which entails sparing the NAC as well
as a variable amount of breast tissue. Ideally, NSM removes all detectable
breast tissue.
Historically, concerns regarding sparing the NAC included oncologic
safety, technical difficulty, aesthetics (final nipple position), and viability
of the nipple. There has been a growing acceptance of the procedural utility
of NSM. The guidelines utilized in deciding which patients are appropriate
candidates for NSM are based on metrics used to preoperatively predict a
lack of NAC involvement and the anticipation of an acceptable cosmetic
result.
193

194
Principles and Techniques in Oncoplastic Breast Cancer Surgery
11.2 Rationale
The rationale for this type of mastectomy is straightforward. The abil-
ity to perform a mastectomy in a woman while leaving the NAC in place
allows surgeons to accomplish 2 goals: to achieve optimal oncologic sur-
gical treatment and to markedly improve aesthetic outcome. The basis of
routinely removing the NAC is increasingly being brought into question as
a necessary aspect of the mastectomy.
The psychological benefit of being able to undergo NSM with immediate
reconstruction aids in facilitating the healing/recovery process as incidence
rates of depression and anxiety can be markedly elevated at the time of
a breast cancer diagnosis. Sparing the NAC potentially leads to greater
patient satisfaction, body image, and psychological adjustment.1,2 Women
report feeling a “psychological calmness and wholeness” as well as a more
natural appearance in relation to opting for NSM.3 Petit et al. reported a
total of 91% of patients feeling “less mutilated” by choosing NSM.4 Many
women who undergo SSMs never undergo subsequent nipple areolar cre-
ation. They therefore never achieve a near-normal breast appearance.
11.3 Why Not Perform NSM?
The standard mastectomy entailed removing the NAC, and routine NAC
excision was based on a presumption of possible NAC involvement, con-
cern for NAC viability, and risk of recurrence. An improved understanding
of nipple anatomy and disease extent has led to the understanding that
this is often unnecessary. Although the NAC can be reconstructed after a
non-NSM, many women do not opt to undergo this procedure. Maintain-
ing the native NAC results in a superior cosmetic result compared with a
reconstructed NAC. Issues that arise include tattoo fading and variability
in the long-term appearance of the reconstructed nipple. Preserving the
main landmark of the breast, the NAC, allows breast cancer patients to
feel “more intact” and experience better aesthetic outcomes. In the setting
of mastectomy, the ability to provide NSM with immediate reconstruction
enables the surgical team to provide a postoperative mastectomy breast
nearly identical to its preoperative appearance. Here we discuss the role of
NSM with a focus on basic science, patient selection, preoperative evalua-
tion, intraoperative technique, and outcomes.
11.4 Most Frequently Cited Landmark Study
When discussing the role of NSM, many people point to the series of sub-
cutaneous mastectomies performed at the Mayo Clinic from 1960 to 1993.5

Nipple-Sparing Mastectomy
195
In this study, subcutaneous mastectomies were defined as removing ≥90%
of breast tissue and leaving residual tissue beneath the NAC. This was
a cohort of 639 prophylactic mastectomies performed on moderate- and
high-risk (Gail model) patients. After a 14-year follow-up, they reported
an 89.5% risk reduction (p < 0.001) in the moderate-risk group and a 90%
risk reduction in the high-risk group. They also noted no difference in breast
cancer incidence between TM and subcutaneous mastectomy. To reiterate,
NSM attempts to remove all breast tissue, whereas a subcutaneous mas-
tectomy may not.
11.5 Basic Science
11.5.1 Breast Ductal Anatomy
The median number of ducts is 23. There is no correlation between duct
number and age, breast volume, or nipple diameter. A number of ducts
commonly share fewer common openings to the nipple surface.6 Neither
duct position nor duct diameter are predictive of whether a system passes
deep within the breast or terminates near the nipple.6 Mean nipple diam-
eter is 11.1 mm. Mean duct bundle diameter is 5.2 mm.6
Although the goal is to remove all tissue under the nipple, it is interest-
ing to note that Rusby et al.6 reported that leaving a 2 mm peripheral rim
of tissue below the nipple resulted in complete duct excision 96% of the time
and 50% retension of microvasculature. The strongest oncologic argument
against sparing the NAC has traditionally been the possibility of cancer
either originating or recurring within the nipple. Studies have demonstrated
NAC involvement in specimens from non-NSMs 10%–25% of the time.7−10
11.5.2 The Terminal Ductal Lobular Unit
Perhaps the most salient support stems from the status of terminal ductal
lobular units (TDLUs). As most breast cancers originate in the TDLU, it
is important to know if there are TDLUs in the nipple. A study by Stolier
et al. found that out of 32 mastectomy specimens from 22 patients [prophy-
lactic, 22; invasive ductal carcinoma (IDC), 4; invasive lobular carcinoma
(ILC), 1; ductal carcinoma in situ (DCIS), 5], only 3 of the 32 specimens
had TDLUs at the base of the nipple (1, 2, and 3 TDLUs, respectively).
No TDLUs were found at the tip.7
11.6 Proposed Metrics
Ideally, we would be able to refer to a prospective randomized study com-
paring NSM and non-NSM. This is unlikely to be performed, however,

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
Table 11.1.
Patient selection metrics.
Banerjee7
Stages (I,II,II), peripheral tumors <5 cm, irrespective of nodal
status or skin involvement
Rusby10
Multivariable logistic regression model
Loewen13
Mammographic distance of tumor to NAC <4.96 cm correlates
w/NAC involvement.
Voltura25
Careful pathologic assessment of subareolar breast tissue at
surgery.
Crowe26
Tumor size <3.5 cm; peripheral; no NCT.
Crowe27
Tumor size <3.5 cm; peripheral; no NCT.
Yueh3
Tumors <2 cm diameter and >2.5 cm from NAC; no skin or
nipple involvement.
Petit19
Tumor >1 cm from NAC; absence of retroareolar calcs; no
bloody nipple discharge, multifocality ok.
Petit20
Multifocality ok.
Wijayanayagam24
MRI >2 cm from nipple; small peripheral tumors; no skin
involvement.
Sacchini28
Exclude gross NAC involvement and <1 cm radiograph from
areolar margin.
Lagios29
Tumor >2.5 cm of NAC; tumor size <2 cm.
Brachtel9
Negative retroareolar margin, HER2 status, size, distance to
NAC, lymphovascular invasion, node involvement, histologic
grade.
because the current worldwide experience suggests that many surgeons
and patients are increasingly endorsing this approach. We can evaluate the
metrics that have been utilized thus far in patient selection (Table 11.1).
Proposed factors that may aid in identifying good NSM candidates (those
who are the least likely to have NAC involvement) include smaller tumor
size, lack of gross involvement of the nipple, distance of tumor from the
NAC, peripheral versus central location, radiographic distance from the
NAC, and cancer-free core (infra-NAC specimen) tissue.
There are multiple clinical series, reported in the literature, and
unpublished international series with results demonstrating acceptably low
recurrence risk (Table 11.2). Fukuma et al. cite a recurrence rate of <1%
within the NAC at 15 years follow-up of over 1,000 patients.11
The prospective registry of NSMs sponsored by the American Society of
Breast Surgeons Mastery of Breast Surgery Program will provide outcome
measures as well as help in delineating ideal metrics.9 This should prove
to be a robust data set.
Formulas10 and predictive models have been proposed for NAC involve-
ment in NSMs; Rusby et al.10 proposed a multivariable logistic regres-
sion model for predicting NAC involvement in NSMs, and Loewen et al.13
proposed a logistic regression equation with NAC involvement as the

Nipple-Sparing Mastectomy
197
Table 11.2.
Reported risk of recurrence.
Total no. of
Recurrence
nipple-sparing mastectomies
rate
Garwood30
170
Voltura25
51
5.90%
Sookhan23
18
0
Gerber32
60
11.70%
Crowe27
149
4 of 149
Sacchini28
123
4 of 123
Regolo22
70
0
Ueda2
33
5.00%
Petit4
773
1.50%
Petit20
579
0.90% per year
Petit19
1001
1.40%
Petit18
300
2 of 300
Note: Petit,4,18−20 received Intraoperative Radiation with Electrons (ELIOT).
dependent variable, and mammographic distance from the NAC as the
independent variable.
11.7 Selection
The majority of papers published thus far have proposed (mostly through
retrospective reviews and small populations) assessing the following met-
rics when selecting patients for NSMs: Peripheral versus central tumors;
smaller versus larger tumors; presence or lack of skin involvement; nodal
status; and indication (prophylaxis, carcinoma, DCIS, and breast cancer
[BRCA] status) (Table 11.1). Recurrence rates have been unremarkable
(Table 11.2).
Ueda et al.2 found no statistically significant recurrence rate in a com-
parison of breast-conserving treatment (BCT), TM, and NSM with patients
undergoing NSM or BCT, and noted greater overall patient satisfaction in
treatment choice. There have been no documented cases of recurrence in
the nipple when the tissue immediately underlying the NAC was nega-
tive for cancer. Size, shape, and degree of ptosis are important factors to
consider when evaluating patients for NSM.
11.7.1 Size
Size is considered by the plastic surgeon when considering reconstruction
options, as well as by the breast surgeon when considering incision type.
The skin envelope needs to be amenable to being filled by either an implant

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Principles and Techniques in Oncoplastic Breast Cancer Surgery
or a tissue flap. A cup, B cup, or C cup size breasts, for example, are eas-
ily reconstructed with either a tissue expander or autologous flap. Large
C cup, D cup, or greater-size breasts pose a challenge when considering
the choice of reconstruction techniques that allow the space below the skin
envelope to be filled or reconstructed, and the NAC to be left in an accept-
able position. A cup size breasts may be exceptionally suitable candidates
for single-stage permanent implant procedures.
11.7.2 Presence and Degree of Ptosis (Grade 1–3,
Pseudoptosis)
With severe ptosis, for example, optimal aesthetics may not be achiev-
able after reconstruction without a free NAC transfer with skin reduc-
tion or a delayed skin-reduction procedure. The ideal breast shape/size for
NSM with immediate reconstruction is an A cup, B cup, or C cup size.
Breasts of size D cup or larger, or a significant degree of ptosis, do not pre-
clude potential NSM. Techniques such as skin-reducing mastopexy, reduc-
ing mastectomy,14 free nipple transfer, or a larger deep inferior epigastric
perforator (DIEP), transverse rectus abdominis myocutaneous (TRAM),
or extended latissimus dorsi flap will need to be considered/applied. A
delayed skin reduction procedure, 3–4 months after NSM and reconstruc-
tion, is also an option.
11.8 Exclusionary Criteria
Inflammatory breast cancer, Paget’s disease of the breast, or involvement
of the NAC with cancer are definite exclusion criteria.
11.9 Preoperative Evaluation
11.9.1 Clinical Breast Exam
Size, shape, degree of ptosis, location of the NAC, areola size, skin condi-
tion, and prior scars are all noted. If the lesion is palpable at the level of
the NAC, NSM is not an appropriate choice.
11.9.2 Patient History
Factors such as prior radiation therapy, BRCA status, and/or prior breast
surgery are evaluated. If the patient has a history of radiation therapy for
a previous cancer, the integrity and condition of the skin are evaluated as

Nipple-Sparing Mastectomy
199
they would be for any mastectomy. A patient who is BRCA+ may also opt
for a contralateral NSM as part of a risk-reduction strategy. A patient who
has had a previous lumpectomy will be evaluated for utilizing the previous
incision.
11.9.3 Imaging
A thorough evaluation of imaging is necessary in a preoperative evaluation.
The distance of the lesion to the NAC should be measured. Published stud-
ies and case reviews outline utilization of ultrasound (US), mammogram,
and/or MRI to aide in preoperative evaluation in predicting NAC involve-
ment. Some advocate a radiographic distance of 1–5 cm; others utilize a
lack of radiographically suspicious direct extension to the NAC.
Fukuma et al. utilize MRI magnification for optimal radiographic
assessment of the NAC area and will core out the nipple even in the setting
of radiographic evidence of potential NAC involvement. Currently, due to
basic science research done on TDLUs, nipple anatomy, and realized rates
of cancer in nipples, most surgeons rely on the permanent section of tissue
immediately underlying the NAC for definitive management. This nipple
core (tissue excised from immediately under the nipple) tissue analysis
should be done routinely for all NSMs, including those performed in the
prophylactic setting.
11.9.4 Planning
All patients undergoing a mastectomy can be considered potential candi-
dates for NSM. The first criteria that need to be met are lack of clinical
involvement of cancer with the NAC, no evidence of inflammatory breast
cancer, and no evidence of Paget’s disease. The next most important ques-
tion is: “Can the plastic surgeon reconstruct a breast under the remaining
skin envelope?” Location and type of incision alters both technical demand
and the cosmetic outcome.
Work-up is identical to that for any type of mastectomy. Is the patient
amenable to follow-up clinical exams? The patient must understand the
possibility of NAC excision or conversion to areola-sparing if the final path
assessment of the nipple core tissue is involved. Clinical follow-up exams
are important for surveillance.
11.10 Plastic Reconstructive Surgery Considerations
The plastic surgeon involved will be able to assess breast size/shape/ptosis
and decide whether to offer an aesthetically acceptable reconstruction,

200
Principles and Techniques in Oncoplastic Breast Cancer Surgery
underneath the remaining skin envelope, in the event of NSM. Perhaps the
key factor is the ability to provide a reconstructive option which leaves the
NAC in a satisfactory position. Definitive implants, tissue expanders, autol-
ogous flaps, and delayed reconstruction have all been described as successful
options. Some cases may require a larger autologous flap, a skin reduction
with free nipple graft, or a delayed skin-reduction mastopexy. Patients may
opt to undergo a contralateral symmetrizing procedure. All NSMs, includ-
ing prophylactic, should have a nipple core specimen sent to pathology.
11.11 Comorbidities
The viability of the NAC is dependent on the surrounding flaps for blood
supply. Comorbidities such as obesity, diabetes mellitus, significant periph-
eral vascular disease (PVD), smoking, and prior radiation may influence
flap and the NAC viability. Very few articles on NSMs comment on the pres-
ence or absence of comorbidities. There is growing experience in performing
NSMs in patients after a local recurrence from previous lumpectomy, and
RT on women who are judged to have acceptable skin quality.
11.12 Intraoperative Technique
11.12.1 Incision Planning
Possible incisions that may be used for NSM include previous excision site,
radial/lateral, radial/lateral with periareolar extension, radial 6 o’clock,
Wise pattern, inframammary fold (IMF), axillary, trans-areola, and tumor
site if in proximity to skin. For periareolar incisions, an incision limited
to <30% of the circumference13 is thought to be the least traumatic
to the NAC and has been associated with reduced rates of epidermoly-
sis and/or necrosis. Multiple incisions have been extensively reported as
feasible.
11.12.2 Spy Device
This machine uses intraoperative fluorescent imaging (Figure 11.1) to allow
for real-time assessment of blood flow of the skin. Some surgeons15 report
using the device to help optimize incision placement. In the patient repre-
sented in Figure 11.1, fluorescent imaging preoperatively changed the plan
for the incision placement to a lower outer diagonal incision rather than a
radial incision laterally, or an IMF incision. This allowed for preservation

Nipple-Sparing Mastectomy
201
Width: 100%
Level: 51%
Coverage: 100%
94%
64%
64%
69%
70%
Figure 11.1.
Fluorescent imaging preoperatively changed the plan for the incision
placement to a lower outer diagonal incision.
of major feeding blood vessels that would have been traversed and likely
injured in those areas. Postmastectomy fluorescent imaging confirmed
excellent blood supply to all flaps.
11.12.3 Inframammary Fold Incision
An IMF incision may vary in length from patient to patient. This type
of incision may be placed directly into the IMF line or slightly cepha-
lad/caudad pending the anticipated final reconstructed result. Generally,
this type of incision is well hidden post reconstruction. This incision is tech-
nically easier in the smaller breast (A cup or B cup). The distance from
the IMF crease to the clavicle must also be reasonable enough to allow
for instrument length and visualization in order to assure the removal of
all breast tissue. If need be, a counteraxillary incision (the incision used
in sentinel lymph node biopsy [SLNB]) may be helpful in dissecting the
infraclavicular and upper outer quadrant regions. When utilizing an IMF
or radial 6 o’clock incision, it is feasible to develop either the posterior or
anterior plane first. Figure 11.2 represents a patient undergoing expansion
of her tissue expanders (band-aid placement) with IMF line incisions that
are well hidden.

202
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 11.2.
IMF line incision. Band-aids are used at the tissue expansion injection
sites. The skin incisions are well hidden in the inframammary line (see arrows).
Figure 11.3.
The left photograph shows the patient seen preoperatively. The right
breast was ecchymotic after the core needle biopsy. The right photograph shows the
patient in the postoperative period. Notice the lateral skin incisions bilaterally.
11.12.4 Lateral Radial Incision
A lateral radial incision (Figure 11.3) is perhaps the easiest incision type
from a technical perspective. This type of incision can be performed either
with or without extension into the areola, or periareolarly for increased
exposure. This can generally be accomplished via a length of approximately
4 cm, or extended laterally as far as desired for increased exposure. Sentinel
node biopsy and axillary node dissection can be easily performed via the
same incision.

Nipple-Sparing Mastectomy
203
Figure 11.4.
Radial 6 o’clock incision.
11.12.5 Radial 6 O’clock Incision
A radial 6 o’clock incision (Figure 11.4) also results in superior cosmetic
outcome status after reconstruction as the incision is well hidden. This
incision can be extended into the areola if need be. This incision, as well
as an IMF incision, can be technically challenging with either a large or a
ptotic breast. The addition of a short axillary incision (utilized for SLNB)
may be utilized in facilitating upper-pole dissection.
11.12.6 Previous Lumpectomy Scar Incision
A previous lumpectomy site scar (Figure 11.5) can be utilized via an ellip-
tical excision of the scar. Exposure can be increased by making a counter
axillary incision if needed.
11.12.7 Transareolar Incision
Though infrequently utilized, this type of incision (Figure 11.6) has also
been described as providing sufficient exposure.

204
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Prior
excision
Figure 11.5.
Previous lumpectomy scar incision. The left photograph is a preoperative
view of a patient with a left breast lumpectomy scar that will be excised and used for
completion of the mastectomy. The right photograph shows the same patient postoper-
atively. The right mastectomy was performed through a lateral radial incision.
(a)
(b)
(c)
Figure 11.6.
Transareolar incision. (a) Preoperative view of the patient; (b) Intraop-
erative view of the incision after removal of the breast. The nipple is part of the upper
flap; (c) The postoperative result. The right breast was not operated on.

Nipple-Sparing Mastectomy
205
Figure 11.7.
Tumor site incision and reconstruction with a DIEP flap. Note how
the abdominal skin was limited to cover the area of the breast skin excised with the
mastectomy.
11.12.8 Tumor Site Incision
An
incision
may
be
made
directly
overlying
a
superficial
tumor
(Figure 11.7). Sentinel node biopsy and axillary node dissection may be
performed through prior lumpectomy incisions when located in the upper
outer quadrant of the breast. The patient presented in Figure 11.7 had an
immediate reconstruction with a DIEP flap.
11.13 Endoscopy
Performing NSM via endoscopic technique has been utilized by our
Japanese colleagues for many years with excellent cosmetic and oncologic
results. A recently published article16 outlines a case series of 89
mastectomies performed for breast cancer in patients without skin or nipple
involvement. They reported a follow-up period of 52 months demonstrat-
ing distant recurrence in nine patients, no local recurrences, and no nipple
involvement. They utilized a 3-cm axillary incision, which was extended to
5 cm if the SLNB was found to be positive and an axillary lymph node dis-
section was performed. They note that this technique is accomplished with
ease among women with small (A cup size) non-ptotic breasts. The ability
to perform NSM with this technique has significant cultural significance
in that it allows women to participate in traditional public bath or steam
room/sauna use with only trace evidence of having ever had surgery.
11.13.1 Endoscopic Technique
The posterior dissection between the breast and the pectoralis major mus-
cle is completed as much as possible under direct visualization. A 30-degree

206
Principles and Techniques in Oncoplastic Breast Cancer Surgery
scope is used for continuing the posterior dissection endoscopically using
either an ultraretractor and/or bipolar scissors. On completion of poste-
rior dissection, they recommend a periareolar incision (less than one-half
of the circumference). They then raise the first 2 cm of the subdermal skin
flaps under direct visualization. Next, a bladeless tracer is utilized to cre-
ate parallel tunnels at 2-cm intervals within the subdermal plane. They
then insert a zero-degree scope and cut the septa with bipolar scissors
under direct visualization. Next, they core the nipple and send the tissue
immediately under the NAC as a separate specimen.
11.13.2 Accessing SLNB
SLNB can often be performed through the same incision utilized for the
NSM. If this is not feasible, a separate axillary incision can be made with
ease. When utilizing periareolar blue dye for sentinel node mapping, it is
not unusual to note discoloration of the skin, which may make it difficult
to assess the intraoperative viability of the NAC. Many surgeons only use
radioisotope to avoid this issue.
11.13.3 Dissection
Dissection can be accomplished either through electrocautery or through
tumescent
injection
with
sharp
dissection.
Dissecting
between
the
subdermal and subcutaneous plane is optimal for flap dissection. When
utilizing tumescent solution, inject it into the subcutaneous space in a
fanning/radial pattern. The area under the NAC can also be infiltrated
in attempts to aid in hemostasis during inframammary NAC dissection.
Sharp dissection then proceeds in between the subdermal and subcutaneous
space. If electrocautery is utilized to raise the flaps, it is recommended to
switch to sharp dissection (knife or metz) for the subareolar tissue/nipple
core in order to limit trauma to the NAC. Light (in the form of lighted
retractors or a light map on the retractor) will significantly aid this process.
11.13.4 Coring
Within the literature, the term “coring” has become synonymous with the
thoughtful, active removal of all breast tissue underlying the NAC. This can
be done safely by everting the NAC over the second finger of the nondomi-
nant hand and utilizing sharp dissection (using either a metz or scalpel) to
excise all the tissue underlying the dermis (Figure 11.8). This breast tissue
is the nipple core tissue sample that is sent separately for pathology analy-
sis. This tissue can be sent for frozen section or permanent pathology. The

Nipple-Sparing Mastectomy
207
Figure 11.8.
Everting the NAC over the second finger of the non-dominant hand and
utilizing sharp dissection to excise all the tissue underlying the dermis.
patient must be educated preoperatively that if this tissue comes back pos-
itive for cancer at any time, the NAC or nipple will be removed (whether
intraoperatively with a frozen section or in the office upon final pathology
evaluation). The NAC can be excised as an office procedure. Patients with
nipple-core involvement can be converted to an areola-sparing mastectomy
with delayed nipple reconstruction. Nipple involvement by invasive carci-
noma or DCIS has been identified by analysis of the retroareolar margin
with a sensitivity of 0.8 and a negative predictive value of 0.96.9
11.14 Additional Technical Notes
If suspicion arises in the OR of possible close skin margin, place a nylon
stitch in both the skin and the specimen directly underlying to mark the
spot. If that specimen comes back with positive anterior margins, you will
already have the skin marked for easy local excision, which can be done in
the office at a later time after flap and NAC healing are complete. Pre-NSM
devascularization of the NAC is a technique utilized by some. The premise
is to make a periareolar incision “several weeks” preoperatively in efforts
to enhance the blood supply after the NSM. Jensen et al.17 described an
incidence rate of 0% nipple necrosis when patients underwent a pre-NSM
surgical delay procedure in the setting of increased risk of nipple necrosis.
11.15 Intraoperative Radiation with Electrons (ELIOT)
ELIOT has been extensively described as a potential adjuvant technique
to add to NSMs.14,18−20 These studies describe an intraoperative RT with

208
Principles and Techniques in Oncoplastic Breast Cancer Surgery
electrons of 16 Gy in one single fraction delivered to the NAC with lead
and aluminum disk protection of the chest wall and pectoralis muscle.
Immediate reconstruction generally entailed a definitive prosthesis, a tis-
sue expander, or, less commonly, a tissue flap. The majority of the pub-
lished work reports a 5-year follow-up of no significant differences noted
between patients receiving ELIOT (800 patients) versus delayed radiation
(201 patients). No noticeable differences were noticed in complication rates
or rates of relapse (0.9% per year, always at the original tumor site, and
never at the NAC) between patient or tumor features.19,20 Surgical tech-
nique in these series varies from the standard NSM. Flaps were elevated
in the subdermal plane, but the infra-areolar tissue was dealt with differ-
ently. The published work did report leaving a “thin layer” of glandular
tissue below the NAC to preserve blood supply.19 Under this preserved
tissue, a small section of inframammary NAC tissue was excised for imme-
diate frozen section; if the frozen section was positive, an additional layer
of inframammary NAC tissue was removed for frozen section. If the sec-
ond frozen section was positive, the NAC was excised.19 Nevertheless, no
recurrence was noted to occur at the level of the NAC.14,18−20 Dr Jean
Y. Petit has reported that he will be starting a trial comparing NSM with
or without intraoperatve radiation therapy.21 It is his belief that ELIOT
is not required for all patients.
11.16 Outcomes
11.16.1 Viability
The viability of both flaps and the NAC are of utmost interest. Perhaps the
most significant factor predicting flap and NAC viability is surgical tech-
nique. Careful and gentle handling and/or retracting of both flaps and the
NAC are important. Full-thickness NAC necrosis, necessitating excision,
has been reported in ≤10% of reported cases.2,14,18,22,23 If epidermolysis
(sloughing) of the NAC does occur, it will typically resolve on its own. If it
achieves a level of full-thickness necrosis and there is risk of implant infec-
tion, the NAC should be excised. If excision is necessary, it can generally be
done in the office. The patient should always be counseled preoperatively
of this possibility.
11.16.2 Sensation
Innervation of the NAC is derived from the anterior and lateral cuta-
neous branches of the second through fourth intercostal nerves. Most lit-
erature reports loss of nipple sensation status after NSM; some degree of

Nipple-Sparing Mastectomy
209
nipple sensation has been reported to be preserved in 15%–75% of reported
cases.14,23,24 Patients should be counseled that they are most likely to have
no postoperative nipple sensation.
11.16.3 Aesthetics
Women report feeling “less mutilated”20,23 when undergoing NSM. They
have also used terminology such as “psychological calmness”; “whole-
ness”; and “more natural appearing.”23 Body-image perception, patient
satisfaction, and psychological adjustment have also been noted to be
superior with NSM.20 Objective cosmetic outcomes and patient satisfaction
have been noted to be superior to a non-NSM and equal to BCT.19
11.16.4 Recurrence Rates
Recurrence should be monitored by clinical exam as after any type of
mastectomy. Most reports in the literature refer to a rate of recurrence of
<10% comparable to TM or BCT with radiation therapy (RT) (Table 11.2).
There are only anecdotal, isolated cases of nipple recurrence at the level of
the nipple. The cumulative world experience both reported in the litera-
ture and anecdotally at scientific symposiums leads us to believe that the
absolute risk of nipple recurrence is extremely small. With this remote risk
of recurrence, management of oncologic consequences should be minimal
with the excision of the nipple. It should also be very easy to detect should
it occur.
In a case series of 579 NSMs with IORT (ELIOT),2 no difference was
found in the local recurrence rate according to patients or tumor features;
recurrences were noted in the tumor bed but never in the NAC. In a study
of 1,001 patients undergoing NSM, a comparison of ELIOT (800 patients)
with delayed RT (201 patients) showed no significant difference in out-
comes, including recurrence.14
Editorial Comment
In the January 2012 issue of Annals of Oncology (PMID: 22231025), Petit
JY et al. published their update of the European Institute of Oncology
(EIO) experience with NSM and ELIOT on 772 invasive cancers and 162
intra-epithelial neoplasias. The median follow-up was 50 months. The in-
breast and NAC local recurrence rates for invasive cancer were 3.6% and
0.8%, respectively. More concerning are the in-breast and NAC recurrence
rates for DCIS, which were 4.9% and 2.9%, respectively. These rates of
recurrence are significantly higher than previously reported with short-
term follow-up.

210
Principles and Techniques in Oncoplastic Breast Cancer Surgery
The mastectomy technique used at the EIO differs from the one
reported in this chapter. The editor would like to caution surgeons on
the importance of long-term follow-up with these new endeavors. The edi-
tor recommends adherence to strict selection criteria, adherence to safe
oncologic techniques of mastectomy, and appropriate training. I also rec-
ommend reporting all NSM cases to local or national registries in order
to maintain tracking of long-term results.
11.16.5 Prophylactic NSM
No evidence of carcinoma or DCIS in prophylactic mastectomy nipples has
been found. The Mayo series may also be considered in prophylactic NSMs.
11.17 Clinical Pearls
11.17.1 What Is the Learning Curve?
When completing your first NSM, it is important to plan an incision that
will result in easy accessibility to all breast tissue (the radial/lateral inci-
sion is the easiest approach to start); one should also have the appropriate
instruments, pay special attention not to place too much tension on the
flaps while dissecting, and remove all tissue underlying the NAC. It is crit-
ically important that the traditional anatomical landmarks used to desig-
nate complete removal of the breast be adhered to in order to insure that
residual breast tissue is not left behind.
11.17.2 What Special Instruments Are Required?
Exposure is typically less extensive when performing NSM. Lighted retrac-
tors or a light map added to the retractors, is extremely helpful. A Bovie
extension and/or long-face lift scissors are also often necessary.
11.18 Summary and Conclusions
11.18.1 Unresolved Issues Postmastectomy
NSM is a type of mastectomy that is increasingly being performed to date.
Recurrence rates have been consistently as low as or lower than those
of traditional mastectomies. Patients benefit from the overall improved
cosmesis and in not having to lose the NAC (or nipple with an areola-
sparing procedure) unnecessarily. Current metrics are evolving. The NSM

Nipple-Sparing Mastectomy
211
Registry of the American Society of Breast Surgeons will provide outcome
measures (local recurrence, locoregional recurrence, and overall survival),
as well as delineated metrics, surgical technique, and patient characteris-
tics, via a prospective registry. Surgeons are currently relying more on the
inframammary NAC tissue specimen to determine the fate of the nipple.
This is a technically demanding procedure. To ensure complete removal of
all breast tissue through limited incisions requires training and mentorship.
We believe that this is extremely worthwhile for patients in terms of qual-
ity of life and aesthetic appearance. For appropriately selected patients, it
is oncologically safe. Our knowledge base will continue to expand as large
datasets are developed through the NSM Registry of the American Society
of Breast Surgeons.
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mastectomy improve satisfaction with cosmetic results, psychological adjust-
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satisfaction after skin-sparing mastectomy for breast cancer with immediate
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8602, Japan.
12. Bloom S, Morrow M (2010) A clinical oncologic perspective on breast mag-
netic resonance imaging. Magn Reson Imaging Clin N Am 18(2):277–294, ix.
13. Loewen MJ, Jennings JA, Sherman SR, et al. (2008) Mammographic dis-
tance as a predictor of nipple-areola complex involvement in breast cancer.
Am J Surg 195(3):391–394; discussion 4–5.
14. Rusby JE, Gui GP. (2010) Nipple-sparing mastectomy in women with large
or ptotic breasts. J Plast Reconstr Aesthet Surg 63(10):e754–755.
15. Bailey L. (2011) Personal correspondence, Lisa Bailey MD, Medical Director,
Carol Ann Read Breast Health Center, Oakland, CA 94609, USA.
16. Sakamoto N, Fukuma E, Higa K, et al. (2009) Early results of an
endoscopic nipple-sparing mastectomy for breast cancer. Ann Surg Oncol
16(12):3406–3413.
17. Jensen JA, Orringer JS, Giuliano AE. (2011) Nipple-sparing mastec-
tomy in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol
18(6):1665–1670.
18. Petit JY, Veronesi U, Luini A, et al. (2005) When mastectomy becomes
inevitable: The nipple-sparing approach. Breast 14(6):527–531.
19. Petit JY, Veronesi U, Orecchia R, et al. (2009) Nipple sparing mastectomy
with nipple areola intraoperative radiotherapy: One thousand and one cases
of a five years experience at the European Institute of Oncology of Milan
(EIO). Breast Cancer Res Treat 117(2):333–338.
20. Petit JY, Veronesi U, Rey P, et al. (2009) Nipple-sparing mastectomy: Risk
of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat
114(1):97–101.
21. Petit JY. (2011) Personal correspondence, Jean Y. Petit, MD, Division of
Plastic Surgery, European Institute of Oncology, Via Ripamonti, 435, 20141
Milano, Italy.
22. Regolo L, Ballardini B, Gallarotti E, et al. (2008) Nipple sparing mas-
tectomy: An innovative skin incision for an alternative approach. Breast
17(1):8–11.
23. Sookhan N, Boughey JC, Walsh MF, Degnim AC. (2008) Nipple-sparing
mastectomy — Initial experience at a tertiary center. Am J Surg 196(4):
575–577.
24. Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ. (2008) Optimizing
the total skin — Sparing mastectomy. Arch Surg 143(1):38–45; discussion.
25. Voltura AM, Tsangaris TN, Rosson GD, et al. (2008) Nipple-sparing mas-
tectomy: Critical assessment of 51 procedures and implications for selection
criteria. Ann Surg Oncol 15(12):3396–3401.
26. Crowe JP, Jr., Kim JA, Yetman R, et al. (2004) Nipple-sparing mastectomy:
Technique and results of 54 procedures. Arch Surg 139(2):148–150.
27. Crowe JP, Patrick RJ, Yetman RJ, Djohan R. (2008) Nipple-sparing mas-
tectomy update: One hundred forty-nine procedures and clinical outcomes.
Arch Surg 143(11):1106–1110; discussion 10.

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28. Sacchini V, Pinotti JA, Barros AC, et al. (2006) Nipple-sparing mastectomy
for breast cancer and risk reduction: Oncologic or technical problem? J Am
Coll Surg 203(5):704–714.
29. Lagios MD, Gates EA, Westdahl PR, et al. (1979) A guide to the frequency of
nipple involvement in breast cancer. A study of 149 consecutive mastectomies
using a serial subgross and correlated radiographic technique. Am J Surg
138(1):135–142.
30. Garwood ER, Moore D, Ewing C, et al. (2009) Total skin-sparing mastec-
tomy: Complications and local recurrence rates in 2 cohorts of patients.
Ann Surg 249(1):26–32.
31. Nahabedian MY, Tsangaris TN. (2006) Breast reconstruction following sub-
cutaneous mastectomy for cancer: A critical appraisal of the nipple-areola
complex. Plast Reconstr Surg 117(4):1083–1090.
32. Gerber B, Krause A, Dieterich M, et al. (2009) The oncological safety
of skin sparing mastectomy with conservation of the nipple-areola com-
plex and autologous reconstruction: An extended follow-up study. Ann Surg
249(3):461–468.

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Chapter 12
RADIATION THERAPY
Robert R. Kuske, Jr.
Arizona Oncology Services Cancer Research Foundation
Scottsdale, AZ 85260, USA
12.1 Background
Lumpectomy and axillary node sampling (for invasive cancers), followed by
breast radiotherapy (RT), has been the standard for local therapy of most
stage Tis, T1, T2, N0, and N1 breast cancers since the late 1980s.1 Like
mastectomy, breast RT aims to cover the whole breast tissue and, when
indicated, the surrounding lymphatics. Because the RT fields encompass a
large volume of tissue, and because they enter and exit through the skin, a
dose-limiting organ, the dose is typically divided into relatively small daily
fractions over 6–7 weeks to reduce side effects and late fibrosis. Landmark
single-institution prospective clinical trials2,3 and a phase II cooperative
group trial, Radiation Therapy Oncology Group (RTOG) 95-17,4,5 have
provided the impetus for a 5-day partial breast irradiation (PBI) alterna-
tive to the conventional whole breast irradiation (WBI) of 6–7 weeks. PBI
has become an increasingly popular option, with low toxicity and excellent
cosmetic outcomes.6
Paralleling the success and growth rate of PBI, oncoplastic surgery
is becoming an increasingly popular method of breast-conserving surgery
(BCS). Oncoplastic surgery uses the best principles of plastic and recon-
structive surgery, melded with optimal cancer surgery techniques of
removal of the tumor with generous margins of normal tissue, frequently
involving quadrantectomy.7 The resulting surgical scars are longer and usu-
ally bilateral, but the size, shape, symmetry, and overall cosmetic outcomes
tend to be excellent.8
215

216
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Many breast specialists would likely appreciate the opportunity to
merge the 2 increasingly popular breast cancer local therapies of PBI and
oncoplastic surgery.
The problem to be overcome, however, is that oncoplastic surgery closes
the lumpectomy cavity so that no seroma develops, eliminating the usual
target for PBI. To perform targeted RT, most techniques require a cavity or
seroma. It is impossible to place a balloon catheter or a multistrut hybrid
brachytherapy device without a space in the breast for the intracavitary
catheter to reside. Interstitial brachytherapy does not require a lumpec-
tomy cavity, but it too requires target volume delineation, which is usually
obliterated by oncoplastic surgery. Taking these factors into consideration,
we find that these 2 emerging innovative surgical and RT methodologies —
PBI and oncoplastic surgery — are not necessarily incompatible.
12.2 Oncoplastic Surgery and 5-Day Interstitial
Brachytherapy
In our practice, we prospectively treat selected women with the following
techniques in response to an observed increase in the number of women
pursing oncoplastic surgery with Tis, T1, T2, N0, N1 (1–3 positive nodes
without extracapsular-nodal extension)9,10:
• A wide local excision or quadrantectomy is performed with clear margins
by at least 1 mm, and usually much wider with sentinel node mapping/
biopsy if the tumor was invasive.
• At least 6 surgical clips are placed prior to moving tissue around and
closing the cavity (superior, inferior, medial, lateral, superficial, deep,
and another where the surgeon thinks the margin is closest).
• Oncoplastic tissue manipulation to close the cavity and shape the breast,
leaving the clips attached to the original cavity wall, with the ultimate
location of the clips ending up in various new locations within the breast.
• A radiation oncology consultation 2–4 weeks after surgery with the
pathology report available.
• Postlumpectomy mammography in radiology (Figure 12.1) and com-
puted tomography (CT) of the breast in radiation oncology to evaluate
where the clips ended up.
• Interdisciplinary deliberation regarding the patient’s candidacy for PBI.
• If approved, the patient is scheduled for image-guided insertion of inter-
stitial brachytherapy catheters at the Arizona Breast Cancer Specialists
facility in Arizona.
• On the procedure day, the patient is positioned supine on the CT table
with arms extended over the head, prepped, and draped in sterile fashion.

Radiation Therapy
217
Figure 12.1.
Mammography after oncoplastic surgery before accelerated PBI. The
breast exhibits a wire taped to the skin over the quadrantectomy skin incision scar.
The surgical clips are noted to extend over the entire quadrant; they provide a clear
target for image-guided interstitial brachytherapy catheter insertion.
• The involved breast is massaged and lifted up and away from the chest
wall, while the template is attached with moderate compression.
• Using 27G and 25G needles, and dilute buffered local anesthetic, 3 path-
ways are locally anesthetized, and 3 anchoring 5F brachytherapy needles,
are inserted through pre-drilled holes in the template to prevent slippage.
• A CT (with 2.5 mm slices) is obtained through the ipsilateral breast and
with the quadrentectomy scar wired.
• The radiation oncologist locates all 6 clips and any postoperative scar on
the CT that is associated with the original lumpectomy cavity, and con-
tours the “lumpectomy” target volume on a 3-dimensional computerized
treatment planning system (3dTPS) (Figure 12.2).
• The 3dTPS increases the target volume by 2 cm in all dimensions, cre-
ating a planning treatment volume (PTV) (Figure 12.2).
• The dosimetrist or medical physicist pulls the PTV 5 mm from the skin
and up to the pectoralis fascia, creating the PTV-eval.
• The 3dTPS rotates the computer rendition of the breast in 3-dimensional
space until the holes in the front and back templates are perfectly aligned.
The PTV-eval is displayed, revealing which holes need to be filled with
brachytherapy needles to cover the grown target volume but avoid the
pleura (Figure 12.2).

218
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 12.2.
A polyphenlylsulfone template is attached to the ipsilateral breast with
moderate compression. The template has pre-drilled holes for the insertion of brachyther-
apy needles that are replaced eventually by plastic catheters with buttons on each end to
prevent slippage. Note the inner darker blue volume that correlates to the clips placed at
the periphery of the cavity after the lumpectomy but before tissue movement and closure
of the cavity. The outer lighter blue volume represents a 2 cm growth of the clip volume
and is the target volume for catheter coverage.
• Diluted local anesthetic mixture with epinephrine is injected down each
planned pathway through the template holes. This procedure is typically
painless and bloodless.
• 5F brachytherapy needles are quickly inserted through the template
with 1.5 cm between needles and 2 cm between rows, for an average of
24 needles.
• The template is disassembled and removed, leaving the needles in the
breast.
• The thin end of the plastic 6F Comfort catheters is inserted into each
needle and pulled through the breast, replacing the needle. The needle
is then discarded (Figure 12.3).
• Later that day or the following day, after the swelling has subsided,
another CT is obtained for treatment planning, source-dwell–position
selection, and dose calculation.
• In dosimetry, we insist on 95% dose coverage of at least 95% of PTV-eval.
The skin dose never exceeds the prescription dose. The 150% isodose
curves between catheters can kiss but not coalesce (Figure 12.4). The
dose homogeneity index (DHI) should be in the 80% to 85% range.
• Allowing a day for the physics team to perfect the dosimetry and sculpt
the dose cloud, brachytherapy starts on the second working day after the
procedure.

Radiation Therapy
219
Figure 12.3.
Photograph of the left breast after the first of 10 brachytherapy fractions
with 26 plastic catheters in place that generously cover the target volume. To cover
this volume after a quadrantectomy requires a myriad of catheters, but the insertion is
painless and bloodless under local anesthetic with the patient awake.
• Using a high dose-rate remote afterloader, an iridium-192 seed (3×1 mm)
is run down each catheter, stopping at 5 mm intervals, with the dwell
time determining the dose delivery to the target issue. With an average
of 10–12 dwell positions in each catheter, there are approximately 250
stopping points of the radioactive seed for each treatment, providing an
opportunity to precisely sculpt the dose cloud by varying the dwell times
at each position.
• 34 Gray is given in 10 fractions over 5 treatment days, with at least
6 hours between fractions.
• After the tenth interstitial brachytherapy, the button on one side of each
catheter is snipped, and all catheters are removed simultaneously with
very little discomfort and no anesthesia.
• Prophylactic antibiotics are not used, but approximately 15% of patients
may need antibiotic treatment for erythema, fever, chills, or other
symptoms.
• The patient is seen a week after catheter removal to evaluate healing and
check for delayed infection.
• The first follow-up mammography is 6 months after the final brachyther-
apy date, with the treated breast being imaged every 6 months for
2 years, and annually thereafter. Cosmetic outcome in one of Dr. Silver-
stein’s patients at 6 months follow-up after image-guided brachytherapy
is shown in Figure 12.5.
Our experience with interstitial brachytherapy and with over 1,600
treated patients has shown recurrence rates of 4% at 5 years and 5% at
7 years.2,11 William Beaumont Hospital in Michigan reported a matched

220
Principles and Techniques in Oncoplastic Breast Cancer Surgery
Figure 12.4.
Surgical clips delineate the edges of the original lumpectomy cav-
ity before oncoplastic movement of tissue to close the cavity. A CT is obtained
in the radiation oncology department with a special brachytherapy template attached.
The 3-dimensional computerized treatment planning system (3dTPS) demonstrates
the surgical clips, contoured on each CT-slice, that are rendered on a 3-dimensional
view with the front and back templates aligned. The top left and right computer ren-
ditions show the catheters in coronal and sagittal views. The bottom left view displays
the highly conformal dose distribution lines (100% red, 150% green, and 200% yellow).
The bottom right view shows a transverse CT slice through the nipple with remnants
of the surgical cavity still evident after oncoplastic surgery, and with catheter coverage
evident and the dosimetry displayed. Please note that the heart/coronary artery dose
with traditional tangential external radiation fields would have been high, minimized by
accelerated PBI.
pair analysis (PBI versus WBI) at 10 years follow-up with no significant dif-
ference in local recurrence, survival, or cosmesis.12 The RTOG 95–17 results
with multi-institution interstitial brachytherapy show a 5% recurrence rate
of 5 years.4 The prospective randomized phase III Hungarian trial with
interstitial brachytherapy versus WBI shows equivalent local control but a
trend toward better cosmetic outcome with brachytherapy.13 Five ongoing

Radiation Therapy
221
(a)
(b)
Figure 12.5.
The cosmetic outcome in a patient 6 months after interstitial brachyther-
apy following breast-conserving oncoplastic surgery.
randomized trials, including National Surgical Adjuvant Breast and Bowel
Project (NSABP)-B39, should shed considerable light on PBI as a 5-day
alternative to conventional 6–7 week WBI, especially in certain high-risk
subsets.
Unfortunately, patients undergoing oncoplastic lumpectomy/quadran-
tectomy with tissue movement to obliterate the cavity have not been
included in the above clinical trials. Our experience so far is at its incep-
tion, with only 12 treated patients. There have been no local recurrences at
a median follow-up of 3 years. All 12 have had good or excellent cosmetic
outcomes without telangiectosia, fat necrosis, or significant fibrosis. The
future success of brachytherapy after oncoplastic surgery will be prospec-
tive clinical trials. Eventually, the number of surgeons who have learned

222
Principles and Techniques in Oncoplastic Breast Cancer Surgery
these techniques will reach a critical mass where such studies are feasible.
However, radiation oncologists must likewise learn interstitial brachyther-
apy, which may prove to be a major bottleneck.
12.3 Oncoplastic Surgery with 3-Dimensional
Conformal PBI
The other major current PBI technique that does not necessarily depend
on a cavity/seroma for RT delivery is external-beam 3-dimensional con-
formal PBI.14 Indeed, this PBI technique has been chosen by 75% of all
participants in the ongoing NSABP-B39 clinical trial who were randomized
to PBI.
Similar to the above discussion regarding target volume delineation
with interstitial brachytherapy, the surgeon must leave clips so that there
is a target for the radiation. The clips should be placed after the lumpec-
tomy or quadrantectomy, but before tissue mobilization and closure of the
cavity. The clips should be placed at the superior, inferior, medial, lateral,
superficial, and deep extent of the lumpectomy edges. An extra clip where
the surgeon deems the closest margin is located can also be helpful.
After tissue mobilization and movement to close the lumpectomy cavity
and shape the breast, note that the clips will ultimately be widely located.
Because of this wide clip separation, defining the target volume can be chal-
lenging. The PTV-eval treatment volume features a 2.5-cm growth beyond
the clips. Multiple beams are tightly collimated with custom blocking to
the shape of the PTV-eval. Our technique, called the “helicopter rotor”
technique, employs 4 non-coplanar beams. The treatment couch is rotated
20 degrees offthe usual medial and lateral tangential fields and then bent
backward by 5 degrees to resemble the angles of a helicopter rotor. The
fields are then blocked to conform to the shape of the PTV-eval at that
angle. There are no published data using the technique after oncoplastic
surgery.
12.4 Intraoperative Radiotherapy During
Oncoplastic Surgery
Another feasible approach to PBI in conjunction with oncoplastic surgery
is intraoperative radiotherapy (IORT). Current methods include electron
beam, intrabeam, balloon catheters, and catheter-based applicators such as
the 2–10 channel HAM applicator. After the lumpectomy/quadrantectomy

Radiation Therapy
223
and before tissue mobilization to close the cavity, a single fraction of
21 Gray is delivered using electron beam. Lead shielding is placed in front
of the chest wall behind the breast tissue to avoid electron penetration into
the lung and subsequent increase in risk of radiation pneumonitis.
Quality assurance with this technique requires definition. Currently,
the volume of tissue beyond the cavity wall that is treated is nebulous and
varies from investigator to investigator. After the electron beam treatment,
oncoplastic closure of the cavity and shaping of the breast are immediately
performed. The advantages of this technique include completion of all local
therapy in 1 day, and skin hooks holding the skin away from the beam so the
skin dose is minimized. Potential issues are the lack of a pathology report
before RT to indicate that the patient is a candidate for PBI, potential
wound-healing problems, and under-treatment of breast tissue clinging to
the skin being retracted during electron beam delivery. A large randomized
Italian trial of intraoperative electrons after lumpectomy is complete but
not yet reported. There are no data regarding this technique in association
with oncoplastic surgery.
Intrabeam delivers soft X-rays using a metal ball that is inserted into
the lumpectomy cavity during the surgery, but before tissue mobilization,
cavity closure, and breast shaping. The soft X-rays do not penetrate deeply
into tissue, so the therapeutic dose only reaches 2 mm beyond the surgical
edge. The dose at 1 cm beyond the cavity is homeopathic, and is negligible
at 2 cm.
Balloon catheters such as the Axxent Balloon Applicator (XOFT,
Sunnyvale, CA, USA) can be used to deliver a single large intraoperative
dose of radiation. As soon as the balloon is inflated, tissue conformance to
the surface of the balloon must be checked. Air pockets or fluid/blood col-
lections are deleterious because they push tissue, targeted for treatment,
away from the dose cloud, and are to be avoided. The skin thickness in
front of the balloon must be evaluated. If the dose is calculated 10 mm
from the balloon surface and skin separation is thinner than 10 mm (which
is usually the case), then the skin will receive a higher-than-dose prescrip-
tion. High skin dose will increase the risk of cosmetic failure, telangiectasia,
and poor wound healing. There are many publications describing the expe-
rience and use of MammoSite (Hologic, Bedford, MA, USA) or Contura
(SenoRx, Irvine, CA, USA) as a 10-fraction/5-day PBI.15 There are no
data using these balloon catheters to deliver a single large fraction intra-
operatively as part of oncoplastic surgery. Again, the limitations are the
lack of a final pathology report to document that the patient is a candidate
for PBI, quality assurance, and potential healing problems after a single
large fraction of RT with a significant skin dose.

224
Principles and Techniques in Oncoplastic Breast Cancer Surgery
12.5 Conclusions
PBI is feasible after oncoplastic surgery. Single-entry balloon and strut-
based catheters are not usable after the cavity is closed, but may be feasible
as a single intraoperative dose. The data from the randomized intraopera-
tive electron beam Italian trial should shed light on the local control rates,
toxicity, and cosmetic outcomes associated with a large single dose of radi-
ation at the time of surgery.
To maximize the possibility of 5-day PBI, we recommend placement
of surgical clips of the cavity wall before oncoplastic closure of the cav-
ity, followed by 5-day interstitial brachytherapy.16 A major advantage of
this approach is ensuring the patient is an appropriate candidate for PBI
before the treatment is delivered. After reviewing the pathology report,
the patient can be scheduled for interstitial brachytherapy 2–6 weeks after
oncoplastic surgery. Three-dimensional conformal external beam PBI is
also feasible, but the skin dose will be higher than brachytherapy, and the
field may be quite large in order to cover 2.5 cm beyond the clips.
As oncoplastic surgery becomes more prevalent, prospective clinical tri-
als will demonstrate the efficacy, toxicity, and cosmetic outcomes of PBI
during or after oncoplastic surgery.
References
1. Boyd NF, Guo H, Martin LJ, et al. (2007) Mammographic density and the
risk and detection of breast cancer. N Engl J Med 356(3):227–236.
2. King TA, Bolton JS, Kuske RR, et al. (2000) Long-term results of wide-
field brachytherapy as the sole method of radiation therapy after segmental
mastectomy for T(is,1,2) breast cancer. Am J Surg 180(4):299–304.
3. Vicini FA, Baglan KL, Kestin LL, et al. (2001) Accelerated treatment of
breast cancer. J Clin Oncol 19(7):1993–2001.
4. Arthur DW, Winter K, Kuske RR, et al. (2008) A phase II trial of brachyther-
apy alone after lumpectomy for select breast cancer: Tumor control and
survival outcomes of RTOG 95-17. Int J Radiat Oncol Biol Phys 72(2):
467–473.
5. Kuske RR, Winter K, Arthur DW, et al. (2006) Phase II trial of brachyther-
apy alone after lumpectomy for select breast cancer: Toxicity analysis of
RTOG 95-17. Int J Radiat Oncol Biol Phys 65(1):45–51.
6. Beal K, McCormick B, Zelefsky MJ, et al. (2007) Single-fraction intraop-
erative radiotherapy for breast cancer: Early cosmetic results. Int J Radiat
Oncol Biol Phys 69(1):19–24.
7. Lebovic GS. (2010) Oncoplastic surgery: A creative approach to breast can-
cer management. Surg Oncol Clin N Am 19(3):567–580.

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8. Clough KB, Kaufman GJ, Nos C, et al. (2010) Improving breast cancer
surgery: A classification and quadrant per quadrant atlas for oncoplastic
surgery. Ann Surg Oncol 17(5):1375–1391.
9. Silverstein MH, Recht A. (2001) Image-detected breast cancer: State of
the art diagnosis and treatment. International Breast Cancer Consensus
Conference. J Am Coll Surg 193(3):297–302.
10. Silverstein MJ, Recht A, Lagios MD, et al. (20090 Special report: Consensus
Conference III. Image-detected breast cancer: State-of-the-art diagnosis and
treatment. J Am Coll Surg 209(4):504–520.
11. Kuske RR, Boyer C, Bolton JS. (2004) Long-term results of the Ochsner
Clinic prospective phase II breast brachytherapy trial. San Antonio Breast
Conference.
12. Chen PY. (2010) A matched pair analysis of partial breast irradiation ver-
sus whole breast irradiation at the William Beaumont Hospital, American
Brachytherapy Society Annual Meeting.
13. Polgar C, Sulyok Z, Fodor J, et al. (2002) Sole brachytherapy of the tumor
bed after conservative surgery for T1 breast cancer: Five-year results of a
phase I–II study and initial findings of a randomized phase III trial. J Surg
Oncol 80(3):121–128; discussion 129.
14. Vicini FA, Remouchamps V, Wallace M, et al. (2003) Ongoing clinical expe-
rience utilizing 3D conformal external beam radiotherapy to deliver partial-
breast irradiation in patients with early-stage breast cancer treated with
breast-conserving therapy. Int J Radiat Oncol Biol Phys 57(5):1247–1253.
15. Nelson JC, Beitsch PD, Vicini FA, et al. (2009) Four-year clinical update
from the American Society of Breast Surgeons MammoSite brachytherapy
trial. Am J Surg 198(1):83–91.
16. Kuske RR. (2008, 2009, and 2010) Breast brachytherapy in women with
breast cancer treated by oncoplastic breast-conserving techniques. American
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INDEX
21-gene assay, 41
70-gene profile (Mammaprint®), 38
acromial span, 14, 16
advantages, margin assessment,
67–69
anterior cutaneous branches, 8
anterior cutaneous nerve, 8
anterior intercostal artery, 4
aromatase inhibitor, 38
balloon catheters, 222, 223
batwing defect, 166
batwing incisions, 164
benelli mastopexy, 172
with radial extensions, 175
benelli’s “round block”, 136
bracketing technique, 92
breast-conserving therapy (BCT), 65,
74
BREAST-Q, 153
calcification cases (DCIS), 80
calcifications, residual, 79
catheter-based applicator, 222
cavity shave approach, 69
circumareolar incision, 178, 182
clip placement, 32
close margin, 70
combining dome mastopexy and
radial resection, 167
coring the nipple, 206
cosmetic outcome, 70
curvilinear incision, 57
Danish Breast Cancer Group, 77
ductal carcinoma in situ (DCIS), 74,
78
disadvantage, margin assessment, 67,
69, 70
disorientation rate (margins), 67
dome pattern, 22
dome incision, 160
dome mastopexy, 160
dome with extensions, 165
donut mastopexy, 174, 175
dose homogeneity index, 218
ductal anatomy, 195
Early Breast Cancer Trialists’
Collaborative Group (EBCTCG),
65, 73, 75
electron beam, 222
elliptical incision, 178, 182
en face shaved margins, 68
endocrine therapy and chemotherapy,
76
endoscopic mastectomy technique,
204
estrogen receptor (ER), 76, 78
examestane, 40
extensive intraductal component
(EIC), 74
EIC-negative tumors, 74
EIC-positive cancers, 74
external-beam three-dimensional
conformal PBI, 222
false-positive margin, 67
227

228
Principles and Techniques in Oncoplastic Breast Cancer Surgery
growth pattern (DCIS), 79
growth patterns of different histologic
types of cancers, 74
Harrison–Anderson–Mick applicator
(HAM) applicator, 222
hemi-batwing, 168
high-grade DCIS, 80
human epidermal growth factor
receptor 2 (HER), 78
HER2-positive tumor, 36
HER2 status, 76
inferior pedicle technique, 145
infiltrating lobular cancer, 74
influence of histology on margin
width, 74
inframammary incision, 62
intercostal artery, 4, 134
intercostal branches, 4
intercostal perforators, 4
internal mammary artery, 4, 5
internal mammary perforator, 184
internal thoracic artery, 6, 134
interstitial brachytherapy, 216
intrabeam, 222, 223
intraoperative radiation with
electrons (ELIOT), 208
intraoperative radiotherapy (IORT),
222
intraoperative ultrasound, 90
invasive lobular carcinoma, 41
inverted “T”, 14, 17, 136
iridium-192 seed, 219
J-mastopexy, 174
lateral axillary fat pad, 122
lateral cutaneous nerve, 9
deep branch, 8
superficial branch, 8
lateral mammaplasty, 137
lateral mammary artery, 4, 5
lateral pedicle, 149
lateral thoracic artery, 4, 134
ligaments of cooper, 3
lines of Kraissl, 57, 89
local control, 65, 75, 78
local recurrence, 65, 73–75, 77–80,
152, 188
locoregional failure, 45
low- and intermediate-grade, 79
lumpectomy, 89
magnetic resonance imaging (MRI),
33, 77, 88
MammaPrint, 41
mammography, 31, 88
margin, 68
margin evaluation, 66
margin width, 80
mastectomy, 73, 78, 80
McKissock Breast Marker, 21
measurement of the mean height of
the lumpectomy specimen, 71
medial mammaplasty, 137
“Mercedes” closure, 115
midclavicle-to-nipple distance, 14
minimal ptosis, 161
mobilization of surrounding
subcutaneous tissue, 103, 122
molecular subtype, 35
Montgomery gland, 10
mosque pattern, 22, 24
multi-institutional intergroup CE
5194, 80
multifocality, 75
negative, 68
negative margin, 71, 75
neoadjuvant chemotherapy, 40, 77
neoadjuvant herceptin, 37
neoadjuvant letrozole, 40
nipple meridian, 14–16, 19, 58
nipple-sparing mastectomy, 193
nipple-to-inframammary–crease, 14
nipple-to-nipple distance, 14
node-negative, 73, 75
node-positive, 73
North American and European
radiation oncologists, 72
National Surgical Adjuvant Breast
and Bowel Project (NSABP)
NSABP B06, 72

Index
229
NSABP B13, 76
NSABP B14, 76
NSABP B17, 79
NSABP B18, 77
NSABP B24, 79
Omega technique, 166
OncotypeDX, 41, 76
parenchymal imbrication, 19
partial breast irradiation (PBI), 215
partial epidermolysis of the lateral
aspect, 147
partial or complete NAC necrosis,
151
pathologic complete response (PCR),
35, 36, 77
pathologic complete response rate, 37
periareolar incision, 60
perpendicular technique, margins, 66
planning treatment volume, 217
poly-ADP-ribose-polymerase (PARP)
inhibitors, 35, 47
positive margin, 67, 68
positive margin rate, 69
posterior intercostal arteries, 7
postexcision mammography, 80
progesterone receptor (PR), 76, 78
preoperative arimidex, 39
ptosis, grading, 198
ptotic breast, 159
purse-string closure, 103
quadrantectomy, 89
radial closure, 103
radial incision, 58, 60
radial margin approach, 66
re-excision, 70–72, 79
recurrence rate, 219
reduction mammaplasty, 131, 178
regional metastatic disease, 33
response to chemotherapy, 34
retromammary bursa, 2, 3
radiation therapy (RT), 65, 75, 78, 79
Surveillance, Epidemiology and End
Results (SEER) registry, 72
sentinel node biopsy, 43, 44
shaved margin approach, 68
specimen orientation, 66
Spy Device, 200
subcutaneous, 2
subdermal system, 2
superficial fascia, 2, 3
superior pedicle, 138
superolateral pedicle, 137
superomedial pedicle, 138
suprasternal notch-to-nipple distance,
14
tamoxifen, 38, 80
tennis racquet, 178
terminal ductal lobular unit, 195
thoracoacromial artery, 4, 6, 134
three-dimensional computerized
treatment planning system, 217
transverse closure, 103
trastuzumab, 76
triangular closure, 103, 115
triple-negative breast cancer, 35, 50
tumescent, 187
tumescent injection, 3
tumescent mastectomy, 183
tumescent solution, 206
tumescent technique, 187
tumor biology, 73
tumor subtype, 76
ultrasonography, 32, 88
United Kingdom, Australia and
New Zealand (UK–ANZ), 79
vascular endothelial growth factor
(VEGF) inhibitor, 47
vertical ellipse, 19
vertical ellipse of skin, 24
vertical limbs, 19
vertical mastopexy, 22
vertical scar mammaplasty, 136
Wise pattern, 17, 136
medial and lateral limb, 19