Good morning. It's my pleasure today to introduce this,
uh, section on posing mastectomy.
I'm Virgilio Sachini. I'm a um breast surgeon at Memorial lung
Catering Cancer centre.
I have with me a co-chair in this session, Doctor Constance Etkin,
that is um breast surgeon at the Zurich Bru Centrum, the largest uh
uh breast centre in uh in uh.
In Switzerland and uh I would open the session introducing Doctor Choi,
Professor Choi, that is uh the plastic surgeon at uh uh at New
York University Hospital in uh in New York.
Uh thank you, Doctor Choi.
S
Oh you have to, oh you have to press cut this side.
OK, I understand. Sorry, um, so full disclosure,
I think that I'm not a breast surgeon. I'm a plastic surgeon who does a lot of breast
reconstructions, so it is a point of view from, uh, breast plastic surgeon just to clarify
here. I have no relevant disclosures.
Wow, this is not advancing and that's advancing so I think I have to look up there um so what
is an aesthetic mastectomy and reconstruction um I don't think it's um.
OK, good. It's not one size or one shape, um,
they come in all shapes and sizes and we just wanna make symmetrical and balanced breasts.
Um, we wanna make sure nipples are in pleasing positions, specially with nipple sparing
mastectomy. In our literature, uh, the most recent article,
uh, says that 45 to 55 ratio, upper pole to lower pole ratio is most pleasing.
Um, I believe that it can be 50/50 or 5545 depends on the size of the breasts
and uh the age of the person.
Um, we wanna make the skin envelope is smooth and scarless hopefully sensate.
I think next speaker is actually speaking on this subject and it's really in the eye of the
beholder in the eye of the woman.
But it's more than the looks, as you all know we want the breast to be physically comfortable
psychologically accepting hopefully they can forget they had a mastectomy uh and
reconstruction and they can play any sports they like so I list these because some of my
patients do play these sports including ice curling and um they can wear any type of bikini
top or gowns and feel confident and sexy and this is our goal with reconstruction.
So what are the key factors in aesthetic nipple sparing mastectomy reconstruction?
We have to get the foundation right and we have to build the breast and you may need to do
revision or touch up to really make them look as good as possible for foundation
I thought of these three things to talk about. I think a lot of you are actually oncolyzic
breast surgeons, so, um.
But you know we wanna make sure oncologically it's safe uh we wanna make sure mastectomy flap
perfusion is good and we wanna coordinate with Neoasin uh chemotherapy.
So in terms of the foundation I'm happy to report that we recently got this paper
published uh of 10 year follow up and this is the longest follow up for nipple sparing
mastectomy uh data and we have a very low.
Recurrence rate in therapeutic nipple sparing mastectomy for prophylactic nipple sparing
mastectomy in 10 year medium follow up in our institution, we had a no cancer occurrence
so it seems to be very uh safe technique um this is just a little bit of our data
showing about 3% rate of um local regional recurrence after nipple sparing mastectomy.
So what do we do with NYU so that we have a pretty good result with this um this is
consistent with consistent with a lot of other institutions.
We wanna make sure nipple to tumour distance is at least 1 centimetre.
Um, you know, we prefer to, but we've done in patients, uh,
about 1 centimetre away.
We do frozen biopsies intraoperatively.
If frozen biopsies are positive, we take the nipple off right then and there.
So, um, false positive frozen biopsy rate at our institution has been 0%.
Um, false positive permanent section rate is about 9.5%.
So false negative rate is about 2%. So in that case,
you can take the nipple off during the second stage, or you can go back obviously to take the
nipple areola complex off.
So this video shows a pulsatile perforator.
Actually I don't think I have uh a laser.
And so our breast surgeons try to save any perforators going to mastectomy flab,
if it is safe to do so.
So mastectomy thickness in our group we found about 8 millimetre thickness is a critical
thickness so below this you get a lot of complications and above this um it's very good.
So this MRI shows before and after a mastectomy and reconstruction it's a some muscular
reconstruction you can see this implant so with a good thickness this is a very stable
reconstruction. So another patient who's relatively thinner and
has a larger implant and very thin subcue tissue layer,
this is more unstable reconstruction, rippling is more visible.
This implant may migrate gradually.
So these are some of the things that we can consider.
The other key factor is thinking about coordinating with neo Ain and Advent
chemotherapy uh for plastic surgeons, um, this is something that we have to really pay
attention to with our own classic colleagues because we know that complications after
surgery can delay.
Uh, treatments, as you know, and in our group we found that autologous reconstruction group
had a higher rate of aspen chemotherapy delay if the complication occurred,
such as mastectomy flat necrosis, and this is sort of a pertinent point because you know in
America average BMIs are much higher and you know they tend to do auto autologous
reconstruction so.
Uh, they are at a higher risk, the higher BMI, uh, group has a higher risk of mastectomy flat
necrosis. So it's something to think about.
So when you're dealing with advanced breast cancer or triple negative breast cancer,
my preference really is to do tissue expander initially, and once the aspen chemotherapy is
over or radiation is over, then I can convert to flat reconstruction.
So this is from our paper um from 2017 and with as new
asthin chemotherapy compared to no chemotherapy there's almost 4 times more uh increased rate
of uh nipple necrosis or a complication.
So it's something to think about and when new asthin chemotherapy is coupled with a
chemotherapy, the rate really skyrockets in our uh study.
With Avi chemotherapy, there's no difference uh with compared to no chemotherapy.
So when a patient will need or is undergoing neo Avi and may need a che uh
chemotherapy after the surgery.
I think that if they are borderline candidate for nipple sparing mastectomy due to ptosis or
macromastia or connective tissue disorder, then it's something that you really think hard about
whether nipple sparing mastectomy is the best choice for the patient.
So once you get the foundation right, I'm sure there are many other factors to think about but
uh just to go on with the uh building of the breasts next,
you know this patient walked into my office and elsewhere.
So if you look at this patient, she got the actually the foundation right it's pretty good,
but just because nipple position is just so off the patient is very unhappy.
So these are the factors to consider. So I borrowed here from Doctor Blade that
looking at the envelope footprint and COA and also looking at the nipple areola position in
nipple sparing mastectomy cases.
Why are these hard? Because as you know,
breasts come in all different sizes and shapes, um, and you know constricted breast massive
weight loss patient previous breast surgery patients are what we see a lot in New York City.
So when the breast envelope is right, it's pretty easy to do one stage direct implant
reconstruction and get a great result.
And we call this direct implant technique breast in a day.
And it's a really a great technique for young patients who are just So upset with breast
cancer diagnosis or BRCA diagnosis.
So therefore, to answer um last yesterday's panel, I don't think that implant
reconstruction will become extinct in my opinion, uh,
with younger patients uh who don't really have much autologous tissue to lend.
Um, this can be done obviously for deep flap as well.
And however when we are dealing with non ideal cases um this is an issue that we have to think
about how do I adjust the volume of the breast?
How do I reposition the areola complex and how do I adjust skin envelope so you can get a
better result. So this is where the plastic surgeons come into
play really thinking about these factors.
Um, this patient has a pretty nice breast but has a slight ptosis,
so a lot of these cases you can do a little manoeuvring during the surgery,
or rotation of the nipple, suturing the nipple to get a,
a very good result.
When the ptosis is a little bit worse and the lower pole is a little bit more constricted,
um, in this case, I tried the two stage approach.
IMF is lower a little bit to centre the nipple in a little better position.
When the patient presents with much greater doses, uh,
then you may need to do bilateral reduction or mastopexy first in BRCA patients.
These are offered and direct implant reconstruction was done.
So this is one stage result, uh, at the bottom.
So the other thing to think about is obviously nipple areola complex position and none of
these uh these exist in isolation you know we are thinking all these coordinated in our head
to make sure that they get the best result possible.
You can do pre-reduction and mastopexy. You can do oncoplastic reduction and nipple
sparing mastectomy. You can do intraoperative skin reduction or
second stage adjustment. All these are possibilities.
So here is this patient with littletosis on the left, uh,
but it's more about the asymmetry which presents a problem for nipple sparing
mastectomy. Um, so what we decided to do is with oncolysic
breast surgeon, she had a pretty significant ADH and calcification which needed biopsy.
And so we did that at the same time as left breast mastopexy.
Uh, and then once that diagnosis was in, then we proceeded with actually bilateral mastectomy
and direct implant reconstruction. I think I could have lifted her a little bit
more, but I think from here to go here I think that you needed something done preoperatively
to get better symmetry in this patient.
This patient had a tissue expander and you can see with tissue expander is riding a little
high in this breast.
Nipple areola complex is a little bit asymmetrical and acentric.
It's due to preoperative breasttosis in this patient.
So during the second stage, and you can see that I have a sizesor in the patient in,
and you can do either crescent mastopexy or periaola uh purse string mastopexy
to centre the nipple a little bit better. So these are the manoeuvres you can easily do.
And you can think about the volume and shape adjustments.
A lot of patients to say, I want to be smaller, I want to be bigger.
So we have to consider that.
Um, so here is this patient who presents with breast cancer,
uh, in her left breast and did a oncoplastic reduction here and symmetorri,
uh, reduction. After that's done, uh, the patient chose to
undergo bilateral deep flaps. And so meanwhile,
she also lost the weight, really transforming her health,
actually. And I think this is an important option for
these patients. When the abdominal tissue is very minimal,
um, stacked deep flap or conjoined deep flap is a great option for these patients,
we get very little fat necrosis or practically none, and obviously size matches better.
And here is this patient that did a uh conjoined deep flap with very small donor site,
and this is not nipple sparing. I did the nipple reconstruction and tattoo
later to get a better symmetry.
So next one is about the revision of the breast reconstruction.
So you can have a worthless painting and then you do a touch up and you can get $450
million. So it's the same thing I think we can really
make our reconstruction result better.
I'm not gonna go through all these lists, but these are all these things we can do to really
make our reconstruction better and so I have some examples so this patient had sub pectoral
reconstruction and a lot of. Animation very lumpy done elsewhere.
It was from back grafting procedure.
So in my mind it was a very difficult case to fix.
Obviously, pocket change is something you can do.
Uh, so I ended up doing a liposuction and tissue expander placement and to
recreate the IMF and then after that was done changed into implant.
Um. So I think that revision is very important.
This is a patient that actually has a tissue expander ins inside too.
They had a very large breast with ptosis and was able to fix that,
uh, during the second stage with periaaola mastopexy and skin.
So with this technique, you know, I deepithelialize without exposing the capsule or
the implant and it is a very, very safe procedure to do if you don't violate the
capsule. Here's another case that uh with had an implant
uh previous augmentation and what I was able to elevate the IMF and downsize her breasts.
Here's another patient with implant dystopia and uh did a capsulloopy and repositioning of
the implant. There's another patient with subpar result.
A nipple was removed due to some atypia and did a fat grafting um to make the result
better. There's another patient with bilateral def
flaps. You can see the skin paddle.
She had a very small stomach.
And here she is after fat grafting and removing that skin paddle.
So in summary we all strive to achieve beautiful breasts for every patient and all
reconstructive surgery is really an aesthetic surgery in my mind I think it's more difficult.
We have to have a critical eye for our own work, listen to the patients.
It is really in the details, minimise number of surgery, how for economical reasons.
Reasons but really more for psychological reasons so that they can go on with the next
stage of their lives and understanding the patient's own aesthetics whether it's regional
cultural ethnic consideration uh should be given.
thank you so much for your attention.
Presentation and I would like to introduce uh Doctor Alana Rebecca that is uh part of the
Mayo Clinic uh group uh in uh Arizona.
Thank you very much.
Thank you all for being here today. um, I'm gonna talk about the preservation of
sensation and mastectomy.
I have no disclosures.
Um, the objectives today are basically to evaluate the impact of,
um, nipple sensation on quality of life, to discuss some techniques and considerations
around that, and also to talk about nipple sparing mastectomy with direct implant
reconstruction. So why do we think about preserving nipple
sensation? Well, there are high expectations for many
patients when it comes to breast reconstruction.
Nipple sparing mastectomy has really actualized the preservation of the nipple areola complex
in implant-based reconstruction, yet we haven't had any significant,
um, quality of life data on how the nipple sensation actually affects that,
um, at this point.
Um, we did just complete and published an IRA approved study about,
um, from a survey for postoperative quality of life, and we use the breastcu as our,
um, as our survey tool.
So we use we uh went through the IRB um to do this and we'll talk about the results of that
later in the um discussion um and then I'll also speak about the availability of autograph
versus allograft um allograft is not available everywhere, so it's a little bit of a challenge
for many countries and then um we'll discuss a little bit about consensus statements.
So nipple sensation has actually been studied for quite some time,
and this is an article from 1996 on the British Journal of Plastic Surgery where they studied
the innervation of the nipple areola complex and the breast,
um, and it has, uh, a good description of the, um, a good,
uh, description of where the anterior as well as the lateral branch of the intercostal nerves
come up into the, the nipple for sensation itself.
And they reported this based on a significant cadaveric study,
um, and then diagrammatically after their cadaveric dissections,
uh, described the lateral and the anterior cutaneous branches to the niploureola complex.
Further from this, um, the there's a group in the Netherlands that actually did an
intercostal block to figure out what the sensory zones were,
um, uh, from the anterior cutaneous nerve.
So they use ultrasound guided um intercostal nerve blocks to evaluate nerves 2 through 5 to
see what the zones were for sensation and where they were overlap.
The interesting thing to me was that when they looked at um the different zones,
oops sorry. When they looked at the different zones,
um, they really, when you read the paper, the area that did not have a lot of overlap was
actually the nipple itself.
Everything else really had different zones of overlap from um other intercostal nerves,
but the nipple areola complex did not.
So, um, that's one of the reasons why it's important to actually target the niplola
complex when we think about re-sensation manoeuvres.
So in our group um we do a lot of infra mammory approach for nipple sparing mastectomies and um
these are some of the nerve endings that are left by our um surgical oncologist um you can
see that they are not consistent um this one I've marked them with a blue surgical marker,
but you can see the areas that of um cautery and.
The areas where they've sort of just gone through and performed their procedure with uh
without really considering whether or not there were nerves there that we needed to um nerve
graft we've been working on discussions and communication and collaboration with them to
ensure that as we move forward that we can have um a better nerve uh donor site uh for our
recipient graft.
So this is um kind of the procedure with an allograft.
Um, you can see here we have the, the mastectomy specimen with nerve.
This is the allograft nerve and nerve conduit to connect the nerves,
um, and this is not on the back table where we connect the nerve with the conduit,
um, with proline suture and then sew that into place over,
um, the ace derural matrix.
And here's another uh example and this is an example of good communication where we have an
excellent um donor nerve.
So that donor nerve is connected to the conduit and the nerve graft and um here you can see the
nerve graft with a slight amount of tension as it's connected to the underside of the nipple
areola complex as we reposition the skin for closure, there's no indentation because it's
not under tension once the skin is repositioned um over the reconstruction.
Um, and this is another example with no dimpling from the nerve graft.
My first, uh, re-sensation patients, I chose smaller volume patients for ease
of the procedure, learning, um, early in this, uh, process,
as well as, um, decreasing tension on the nerve for better,
uh, overall healing.
In areas where there's not um an allograft as an option,
um, many of us have taken several nerve grafts for um cross facial nerve grafts or other um
areas that need nerve grafting in the extremity, um, brachial plexus,
etc. you can take a nerve graft with a tendon
stripper, um, with a couple small incisions and actually.
Um, get a really nice long autograph that can either go,
this was for cross facial nerve, um, but you can either go over a very large volume,
um, autologous reconstruction to directly innervate the nippleal complex or divide that
single serial nerve graft to um graft to smaller direct to implant.
We've also done some um cadaveric studies looking at the intercostal nerve as a
possibility for the patient's own nerve graft, and here you can see that we can get at least 8
centimetres of length, which in a smaller volume reconstruction is easily um uh connected
to the nipple areola complex.
And here we dissected out the um 3rd, 4th and 5th intercostal nerve,
and they all, all of them are um possible donors for a sensory innervation for the nipple
areola complex.
So as we think again about why are we doing this and what the expectations are for the
patient, we looked at um a cohort of patients at Mayo Clinic in Arizona and we used the
breast cue to evaluate their outcomes, um, the outcome of sensation and how that affected,
uh, their quality of life.
So there were 349 patients that received the survey um from 2008 to 2020 and
the metrics between the groups were um reported different amounts of sensation um there and we
split them into complete numbness of an area or uh the uh the rest that had some sensation.
So the 131 patients returned the survey, um, and about 36% had
breast sensation, 34% said they had nipple sensation.
The median time uh of the survey was about 6 years, and,
um, the majority of the patients had bilateral direct implant reconstruction.
So when we look at the uh sensation for the breast itself,
38% of people stated that they had a completely numb breast um with no sensation anywhere on
their breast um and that uh had a significant difference in their overall chest
wellbeing, but it didn't seem to um have a statistical difference between the other
cohorts uh for psychosocial and sexual wellbeing.
But interestingly when we look at the nipple sensation itself,
um, when 57% reported that the nipple was completely numb and in that group it was
statistically significant that chest physical well-being, psychosocial wellbeing,
and sexual wellbeing were all affected um by their nippleloola complex being um insensate.
So, um, what are the takeaways from this?
Long term, um, the breast and nipple sensation, uh, are often significantly diminished in the
majority of patients after nipple sparing mastectomy.
Patients that have preserved sensation experience better physical,
psychosocial, and sexual wellbeing.
Um, nipple sensation affects all aspects of well-being, um,
including the sexual wellbeing, and reinnervation should be considered in this
patient population. So it's obvious that this is not a widely
completed um uh surgery. It it's not done everywhere and because of that
we need to continue our research to assess the role of neuritization and sensation outcomes.
We need to continue to evaluate the quality of life for these patients,
um, and we actually have an obligation to continue forums like these,
um, with a worldwide audience so that we can come up with some great standardised and
reproducible results. Our insurance.
Behind our innovations, so typically when we have a newer procedure,
the insurance um coverage does lag behind, but as we continue to demonstrate the improvement
in quality of life, that's a good way to um to lobby for insurance to actually pay for this
procedure and we have been getting better uh better insurance coverage in our institution,
um, and so I think that in the US it's getting to be less of an issue to have this covered.
Thank you. Thank you, Rebecca, for this wonderful
and interesting talk.
So we are already heading for the last speaker because Ashta unfortunately is not feeling
well today, so it's a great pleasure to introduce Isabel Rubio from Madrid.
So she's very. Experienced um oncologic surgeon and breast
surgeon and head of the department and also the professor in Madrid.
So thank you, thank you very much and good morning everybody.
So let's go to another uh issue when we are doing nipple sparing mastectomies and and
skin sparing mastectomy.
So we know that the local recurrences after DCIS.
Um, if they have ipsilateral invasive event, it will impact and it will decrease
breast cancer specific mortality of patients.
So that's why it's so important to know what are the risks of recurrences in this DCIS
patients. So we have here some of the factors,
uh, and if you look at them, the two last one, the margin weight and the receipt of radiation
therapy. are the only two factors that can be modified.
So we know that positive margins in the CIS after breast conservative surgery can go from 7
to 20% and after mastectomy, the study shows that it can be from 5% to
13%.
Of course, you know, in breast conservative surgery, the reexcision rates for the positive
and close margins can be up to 30%.
But the truth is that close margins, uh, less than 2 millimetres in the mastectomy setting
are very heterogenously managed.
Um, after the guidelines that published the margin with for invasive and,
and DCIS breast cancer for the margins, we saw that in,
in the invasive setting, there was a really decrease in re-excision rates.
But the reported the studies on this CIS has shown that after the guidelines showing that
with a margin width of 2 millimetres or higher than that was enough
pathologically complete, um, we have seen from the data that the re-excision rate has not
changed much, even though there are some studies.
Uh, that the re-excision rate has increased, and this is probably because in this CIS,
many, the majority of patients were not reexcised when the margin was less than 2
millimetres. So I think that with this CIS we always have
this genusly depending on the margin width.
Of course, we are doing more and more nipple mastectomies and the initial indications almost
10 years ago were that, you know, tumours need to be small away from the nipple are complex,
negative axilla, but nowadays it's true that we have an increasing eligibility in patients.
We really Sorry, we really don't depend on tumour size,
don't depend. We only make sure that there is no clinical or
radiological, well this goes by itself.
Uh, radiological nipple involvement, we don't, you know,
it's independent of the EMI or axillary status, but still there is a selection.
So when we talk about anatomic variations and you know,
I know that plastics like to talk about, you know, if it's thick or thin and for us,
you know, I, I really don't like that because, you know,
it depends on how the breast is, so probably in the right side,
you know, the, the flap is thinner.
On the left side, the flat is thicker, but what is really important is where you do the
mastectomy flap.
And I think the important thing is just to go to the superficial layer of the superficial
fascia that you can preserve um the dermis, the all the irrigation to the dermis and also,
you know, excise the majority of the, of the breast tissue.
Of course, this is not always as easy as the picture.
Uh, but this is what we really try to do. And when we start doing the nipple sparing
mastectomies, we were only worried about the nipple are complex.
I mean, we, it seems that we were worried about recurrencies there.
We do frozen section in the return area and, and, and it seems that we didn't worry about
the flaps. We just worried about the nipple and what
happened with that, that when we look at the different um At the different studies already
with 1000 numbers and with follow-ups higher than 5 years,
we see that the recurrences in the niparial complex are really low,
but we have the recurrences in the flaps.
And this is what we really need, we really have learned now after many years doing nipple skin
sparing mastectomy that the nipple is just another margin.
So as much as we care about the nipple aorta complex margin,
we need to care about the flaps margin.
So there are some studies that have shown um in DCIS uh nipple sparing mastectomy and skin
sparing mastectomy, what are the rates of positivity of the margins and you can see here
um that it can go from 8 to 25%.
And they call it positive also if the margin is less than 1 millimetre,
you can see that the follow-up is high, and more than 5 years in all of them,
and the local recurrence rate is about mainly the same in all,
around 4.5%. There is this study just recently published
from, from Finland.
With extensive DCIS because these other ones included also,
I mean these numbers are for DAS but were higher, bigger studies with invasive.
This one with extensive DCIS, 12% of positive margins, um 71 months of
follow-up, that's a good number. No.
Recurrences, but if you look at the way they treat the positive margins,
it, it is so there is a great variability. So in some studies,
they give radiation therapy to the positive ones.
In some of them, they just do reexcision. In some of them,
the group from Milan uh use the Intraoperative radiation therapy to the nuclear complex.
So the majority of this, you know, it's difficult to get a conclusion on how to deal
with this, uh, with this positive or very close margins of this area in the mastectomy setting.
Because they consider close margin, a different margin width because positive margins are
managed differently and um in the majority of the studies,
we don't know which one is the positive margin. So it doesn't er in the report,
it doesn't explicitly say that it's the posterior, the anterior or,
or which margin is positive.
And we know that when um depending on, on where we do the incision,
sometimes we can increase the risk of positive margins.
I think that I like this study, but I think that the more nipple sparing mastectomies that
you do, the more inform um.
The incision that you use, um, the more confident you are that you are not living um a
positive margin.
But it's true that if you are using informal incisions like this,
if the tumour is very high up here, they have seen that the positive margins are higher
compared with The other type of incisions, even though with this other incisions we know that
there is an increased risk of nipple necrosis.
We start when we start doing nipple skin spray mastectomies, we always use like a super
areolar incision with a uh with um an extension to the right.
I mean we had partial necrosis very often.
Because we were worried about the narra complex. Nowadays, the majority of the patients get or
um inflammary fold incisions or, or if they need a wise pattern.
So what can we do to reduce this margin positivity?
Because you don't want to do a patient with DCIS, uh,
put an implant in one stage and then come back with a positive margin and then the patient
needs radiation. I mean, mm, it's kind of a, a difficult
situation to deal with.
So we, we did this study many years ago, um, looking at uh doing the mastectomy and this is
skin sparing mastectomies for DCIS. You can see here,
we send the mastectomy specimen to, to pathology department.
they just say ink the margins, cut it, send it to radiology and look at what was the
concordance between um the uh specimen radiograph with the pathology and as you can
see here, in those patients where there was a close margin,
one patient has a positive margin on the final histology and the if the margin was free,
the majority of them were free. But even though there was 9% of patients who
has a very close margin.
So this helps us in that study with 30 patients to, to find out that sometimes we can re-excise,
we reexcise 3 patients um because there was microcalcifications close to the margin.
But let me tell you that this is so time consuming and you have to,
you know, you have to convince the pathologist to.
you know, in this, the specimen caddy. You have to convince the radiologist that when
the specimen arrives to the radiology department, they need to stop mammograms and do
this. So at the end, you know, if you have high
volume, this is looks very nice but it's really time consuming,
so we really don't do that anymore.
So what we are doing now is that we are using the intraoperative ultrasound to assess the
superficial margins.
So this is a patient um that has a breast conservative surgery in this area.
She has a she has implants before, she has breast conservative surgery.
Vision therapy and she developed in the in this area where the tumour was.
She had uh it was a neat to one patient, then she had surgery,
pathological complete response and two years later she developed a local recurrence in the
breast, OK, here.
And this was DCIS. It was a biopsy and it was DCIS you can see
here that the tumour is. So what we do now is that um.
Let me see if Um, can we, can we start the video, please?
I don't know if I can do it from here.
Uh, Yeah, because I don't have a mouse.
Can we start the video, please? Oh, OK.
So, before the surgery, uh, so, We just do an ultrasound and you see here
the DCIS where the tumour, the recurrences. So we measure the distance from the skin
to, to the tumour and we can see it very clearly here and we just mark the area and you
can see the the incision that the patient has for the um previous surgery.
She also had this one because she has implants many years ago,
um, and we mark always in the skin.
Uh, where the tumour is, the closest area that we are,
uh, that we have, uh, seen on the ultrasound.
You can see here that we do the mastectomy flap.
Um, can we skip a little bit?
So, OK.
So we just keep doing it, um.
The way we do it and we always make sure that we don't lose the marks that we have done in
the skin. Now we are approaching the tumour, um.
Can we skip this a little bit? We decided to preserve the nipple are complex,
uh, and place a spander because the patient has has radiation therapy.
Um, we also do the retro um
Oh, it's gone. OK.
We also do the retro um tissue assessment for protein section,
um. That it's this and then, you know, we just
already passed the area where the tumour was and then at that point,
we just take out the, the implant because it was making us uh more difficult,
the surgery.
We take the specimen out.
And then what we do is um We check with the ultrasound, we mark the tumour,
we, and you know, it's uh you just get an agreement with the pathologist and how you mark
it. um and then we check, we check the, the tumour
and we Uh measure the distance from the tumour that it's here to the,
to the superficial um margin because we have, in this case,
you the, the margin was only 2 millimetres.
We go back and because we have marked the area, there is always some uh and this is,
you see, the dermis there already, we can always take some uh uh additional tissue
um to avoid a positive margin there.
So, um, in conclusion, well, we have already 60 patients, um,
50 of them are invasive and 10 are um DCIS.
Uh, we will present it next year, or in next year, next month in the European Society of
Surgical Oncology meetings, so I cannot give you.
the data, but I can tell you that uh we have uh uh some patients where we did reexcision
intraoperatively and that makes that the patient has a negative margin that if we
haven't done this, and the patient would have uh less than 1 millimetre margin or a positive
margin. So I think it's important that we report all
the margins when we do nipple skin sparing mastectomies, um,
or, or skin sparing mastectomies. Of course,
you know, the nipple skin mastectomy requires expertise because we need to leave the minimal
residual. Breast tissue and preserve the viable flaps.
Um, as I mentioned, you know, we, we don't really need to be afraid about the nipple.
We just treat that same as we do with the rest of the margins and we need to be very careful
with the margins, uh, the flap.
Um, we can reduce the positive, uh, anterior margin by using the intraoperative ultrasound.
Studies are really controversial whether we need to add radiation therapy to those patients
who have close margins, less than 1 millimetre. There are some studies that shows that with the
radiation therapy, there is, um, they lower the risk of recurrences,
but there are others that say uh don't, but the problem is the,
the diversity of how they measure these margins and I think that at the end.
If we get a patient with a very close margin or or a positive margin after a nipple skin
sparing mastectomy, we need to do an individual assessment in the multidisciplinary setting
because it's not only considered that there is uh a less than 1 millimetre margin.
It's important to know what is the margin, if there are other margins that are close,
what is the age of the patient, what type of DCIS and so on.
So thank you for your attention.
Thank you, Isabel.
Um, are there questions from the audience?
So I, I have a first question for Doctor Choi.
So, mm, you, you, you assess the by frozen section, uh,
the retrarela tissue, and uh if it is positive and you did uh an inframammary
incision. Are you confident to remove the nipple and the
reola right away?
Because of course you have a breach of skin that may not be vascularized and uh we are
very concerned about the possible necrosis.
Yeah, absolutely. So if somebody else.
Absolutely, um.
Yeah, that is my concern.
And but we haven't had any necrosis. I think that if you're suspicious that nipple
areola complex may have to come off and the breast surgeon agreed to do nipple sparing
mastectomy, then, um, when we're doing mastectomy, obviously we're extremely
careful to have nice well vascularized flap.
And um when you do the nipple areola excision often my uncle Azi colleagues
would ask me to do it so uh I take the responsibility and um it is definitely having
parallel incision is nerve wracking.
But often um you can um do it without any issues so I haven't had any problem with
that. We, we are, we are doing less and less a frozen
section we wait for the final pathology and at the time of the exchange of the implant we
prefer to excise or if we have some room, some uh some room for
uh another excision of the reducts we do.
And we ask a frozen section during the exchange.
Yeah, absolutely, I, you know, only time that we would really commit to removing is if
actually involves breast cancer.
Yeah, we, we usually don't, so we start exercising the nipple are complex uh when there
was a positive margin intraoperatively, but now we don't,
we leave the areola. We are not excising the areola.
We just excise the, the nipple.
So Elizabeth. about the sensation bearings.
My first question is Structure the nerve graft to the
Thank you under the nipple areola complex, um, so that's my first question.
So at the edge of the nipple areola complex you can typically see um the fifth intercostal
nerve, uh, it'll have a little stump, um, at the end and we basically connect it to that
stump if that stump isn't highly visible.
Um, then I'll connect it just to the subcutaneous tissue of the,
um, underside of the uh nipplelola complex, um, so that it can,
um, grow in a little more randomly, but typically there's a small stump that you can
identify and and so too.
Uh, I've also, what I've done is with that allograft or nerve graft,
the epinurum, um, you can actually sew the epineurum directly to the border of the nipple
in the underside so it becomes like a little like, you know,
web of web of nerve endings going directly to the sub nipple area.
Very interesting. And secondly, what, what's your success rate,
and have you had cases where you've actually um patients report pain or um this urine?
So, um, we're collecting data on sensation, um, afterward I have a
patient that is currently about 3 years out, uh, who asked for a nipple reduction surgery and
she had pain on removal of those sutures which I thought was pretty amazing.
Um, and I have a patient, um, who's about 14 months out who's reported that she has,
um, more sensation now than she had preoperatively, so there are patients that um
are reporting that they don't have great sensation, but um I think the key is
really to um.
Add some stimulation to their healing process.
It takes about 9 months for them to really feel anything, so they need to be
stimulated just like they would normally people would rub their reconstructions and and
stimulate the skin. They need to stimulate the nipplelola complex
as well in order to really uh know when they're having sensation.
And is that sensation that comes back what sort of quality has that sensation,
for example, is it possible for women to have like sexual pleasure feeling?
So the one, the one woman that's 14 months out is actually a colleague
of mine's sister, so she came in for her, uh, graduation from residency,
and, um, she told me that basically.
Uh, at first she had her partner um touch her breast with and her nipple,
um, when she had her eyes closed and initially she could not feel it with her eyes closed,
but she could interpret it with her eyes open, um, and over time now she has um full function
of, uh, and sexual function with her nipple that took about a year for her to um get to
that point. So do you, do you do it in all your nipple
sparing mastectomies? I am now sorry my microphone is right here.
um I have been now um we did not during the pandemic because it was challenging to get,
um, it's really loud, uh, it was challenging to get the nerve grafts.
They weren't the um.
They weren't allowed to come into the hospital, um, but since the end of the pandemic and the
um and sort of back to normal work we've been doing it on everyone who's directed implant and
nipple sparing. I have not done it in um autologous tissue as
of yet. I know that people are.
Actually we're doing an IRB study of split chest so I don't know who's gonna sign up for
it, but we're gonna do nerve grafting on one side for bilateral cases and not on the other
and really assess objectively what the difference might be.
And I think one of the important things is that it has to be done at the time of the mastectomy.
It is so hard to find anything in the scar tissue that if you don't do it right away,
then it's, it's pretty much futile to try.
And then someone is claiming to do the nerve sparing mastectomy.
What do you think about it?
So I think so I think that with careful dissection, um,
many of the nerves as they go into the subcutaneous tissue can be spared,
and I think that that's probably the difference, um.
Basically some of the people having really good sensation afterward and some not having any
sensation is how the mastectomy was done so with careful consideration of the neurovascular
bundles as they come into the subcutaneous tissue, um,
you can get great sensation the. Interesting thing from the Netherlands article
was that there's not the crossover to the nipple itself so as we say the nipple,
we're still cutting those nerves and that that's why that is a good target,
but the rest of the skin with a careful mastectomy can get great sensation.
Isabel is is absolutely right that our concern as a breast surgeon is to remove
the whole breast tissue, especially in BRCA patients, because if you leave breast tissue,
sooner or later the patient would have a breast cancer.
So of course, probably the mastectomy then the by the plastic surgeon and the breast
surgeon may be a little different.
I was wondering, is it just about the flab thickness or the envelope thickness,
or is it also about the approach like the incision or It's interesting sometimes what you
can see um the so the lateral branch kind of goes into two branches and you can see one
going into the sub Q and I've actually um followed it up into that subcutaneous tissue
and grafted a shorter graft, um, and it really is it's really just dependent on
the that ref section that day from surgeons because it's not always consistent.
Um, because the breast tissue is not always consistent.
Any other question?
so I closed this very, very interesting section. Oh please,
of course. I have a question for Doctor Rubio,
thanks for this, um, excellent, um, overview and your um um approach there.
So what is your approach with extensive DCIS that you usually cannot see with ultrasound and
sometimes we have these skinny patients and it's all up to the,
to the skin, the breast tissue.
So is it something you decide then afterwards to go back and then where do you go back?
So, um, the majority of cases, uh, in the invasive cases and then the other ones I think.
We don't have a problem because uh um we can see the tumours,
I mean the majority you see on the ultrasound and um we use this uh clips that are
visible on the ultrasound.
So if we don't, if the tumour has a complete response, a terminal one treatment,
we see the clips.
In DCIS like this patient that I show, sometimes if,
if the DCI is is extensive. And you have this more uh bigger
microcalcifications, you can see the areas in, in by ultrasound because we have now you have
ultrasounds that has probes until 18 megahertz, so, so you can
see pretty well the the calcification. We have a very small um ultrasound probe that
we can introduce in the breast also.
In those ones that are very tiny microcalcification and we don't see them.
If, if they, if we find some microcalcifications in the mammograms that are
very close to the skin, we, we tell the radiologist to place uh uh ultrasound visible
clip there so we can manage that.
But in those cases, I mean, we just see the clip and,
and uh we just follow that.
Uh, and there are cases that still you probably get, I mean,
um. A positive margin, but we, we are very much
concerned and we are very much um um considered when we are doing the mastectomy flap where the
tumour is closed.
So we have the clip and we know that that area we need to be very close to the skin.
So, so we, we really, you know, are, are very much into looking at the flaps that
uh where the tumour is.
Thank you, thank you again.