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Outcomes of Nipple-sparing Mastectomy with Reconstruction after Recent Oncoplastic Wisepattern Reduction
Salman Choudhry^*1, Tasha Martin², Tripp Holton¹, Rubie S. Jackson^2
1Division of Plastic Surgery, Anne Arundel Medical Center, Annapolis, MD; ²Department of Breast Surgery, Anne Arundel Medical Center, Annapolis, MD

For patients with large and/or ptotic breasts, a planned staged approach to nipple-sparing mastectomy (NSM) has been described. Less is known about surgical outcomes of unplanned staged NSM for management of positive margins after partial mastectomy with oncoplastic reduction. It is not clear from earlier studies whether an interval of less than 10 weeks between oncoplastic reduction and NSM is feasible, when a shorter interval is important for oncologic reasons.
This is a single institution analysis of patients from 2018 to 2021 with a diagnosis of invasive cancer or ductal carcinoma in situ who underwent NSM after oncoplastic breast reduction for positive margins or nodes. The primary endpoint measured was nipple loss. Secondary outcomes were need for operative re-intervention and wound complications.
Nine patients (14 breasts) underwent partial mastectomy with oncoplastic Wise-pattern breast reduction, followed by NSM. Three patients underwent intersurgery chemotherapy. The average interval between oncoplastic reduction and NSM was 11.3 weeks when excluding patients undergoing chemotherapy (range 8-13 weeks). Thirteen breasts (93%) underwent pre-pectoral direct-to-implant reconstruction. One breast (7%) received autologous reconstruction. One breast required reoperation for seroma. The rate of partial or total nipple loss was 0%, with an average follow-up of 1.6 years.
Our experience demonstrates excellent outcomes from NSM after oncoplastic breast reduction, with the majority of patients undergoing single-stage pre-pectoral direct-to-implant breast reconstruction. Overall, patients had a shorter intersurgery interval, compared with prior studies, with no cases of nipple loss. An intersurgery interval of 8 weeks may be feasible when avoiding delays is important for oncologic reasons.

Table 1. Patient Characteristics and Tumor Type

Patient	Age At Diagnosis	BMI	Average SNTND (cm)	Breast Cup Size	Breast Involved	Quadrant	Tumor Type by Excision	Smoking Status	Free Nipple Graft	Follow Up (mo.)
1	44	31	29	38D	Right	UO	DCIS, IDC	Never	No	27.5
2	57	40	41	42DDD	Right	LO	DCIS, IDC	Never	Yes (U)	25.4
3	38	49	42	44F	Right	UI	DCIS, IDC	Former	Yes (B/L)	23.7
4	43	30	n/a	34DDD	Right	UO	DCIS, IDC	Never	No	24.3
5	46	22	24	n/a	Left	LI	DCIS, IDC	Never	No	2.0
6	58	32	29	42A	Right	UO	IDC	Former	No	21.8
7	50	35	33	40DDD	Left	UO	Mixed IDC	Never	No	2.8
8	52	22	24	36B	Right	UI	DCIS, IDC	Never	No	0.3
9	55	31	29	36C	Left	UO	ILC	Never	No	5.2

DCIS, Ductal Carcinoma in Situ; IDC, Invasive Ductal Carcinoma; Invasive Lobular Carcinoma; SNTND, Sternal Notch to Nipple Distance; UO, Upper outer; UI, Upper Inner; LO, Lower Outer; LI, Lower Inner; Unilateral, U; Bilateral, B/L

Table 2: Interval Between Oncoplastic Reduction and Method of Reconstruction

Patient	Mastectomy	Weeks Between Reduction and NSM	Chemotherapy	Method of Reconstruction	Tissue Perfusion Assessment (SPY)	Dressing	Implant Size (cc)	Partial Mastectomy Weight (g) with Margins	Reduction Specimen Weight (g)	Left Breast Mastectomy Weight (g)	Right Breast Mastectomy Weight (g)
1	Unilateral	13	None	DIEP	No	Prevena	n/a	69	89	Unilateral	594
2	Bilateral	20	Neoadjuvant	pDTI	Yes	Prevena	800	517	935	1229	885
3	Unilateral	8	Adjuvant	pDTI	Yes	Prevena	800	108	1818	Unilateral	1254
4	Bilateral	21	Neoadjuvant	pDTI	Yes	Conventional	800	245	747	535	703
5	Bilateral	29	Neoadjuvant	pDTI	Yes	Bella	495	26	14	432	406
6	Unilateral	11	Adjuvant	pDTI	Yes	Bella	485	35	88	Unilateral	385
7	Unilateral	13	None	pDTI	Yes	Bella	650	230	540	686	Unlateral
8	Bilateral	12	None	pDTI	Yes	Bella	240	1720	155	189	202
9	Bilateral	11	Adjuvant	pDTI	Yes	Bella	520	109	382	374	440

DIEP, Deep Inferior Epigastric Perforator. pDTI, Pre-pectoral Direct To Implant


Clinical photos, patient 5. A, Pre-oncoplastic breast reduction of patient 5 after core needle biopsy with left-sided breast cancer, grade II ptosis and a body mass index (BMI) of 22 kg/m2. B, The patient 3 months postoncoplastic breast reduction. C, The patient 2 weeks post-NSM with pDTI breast reconstruction and placement of 495 cm3 extra profile implants. The patient received chemotherapy between oncoplastic reduction and NSM, resulting in a 29-week interval between reduction and NSM.


Clinical photos, patient 6. A, Pre-oncoplastic breast reduction of patient 6 with right sided breast cancer, grade II ptosis, and BMI of 32 kg/m2. B, The patient 16 days postoncoplastic breast reduction. C, The patient with placement of Prevena Restor BellaForm dressing which was removed at the first postoperative visit. D, The patient 16 days post right NSM with pDTI breast reconstruction and placement of 485 cm3 full profile implants. Interval of 11 weeks between breast reduction and NSM. Postoperatively, the patient developed mild right nipple epidermolysis, which healed by conservative measures.

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