Prospective pilot study protocol evaluating the safety and feasibility of robot-assisted nipple-sparing mastectomy (RNSM)

IntroductionNipple-sparing mastectomy (NSM) can be performed for the treatment of breast cancer and risk reduction, but total mammary glandular excision in NSM can be technically challenging. Minimally invasive robot-assisted NSM (RNSM) has the potential to improve the ergonomic challenges of open NSM. Recent studies in RNSM demonstrate the feasibility and safety of the procedure, but this technique is still novel in the USA.Methods and analysisThis is a single-arm prospective pilot study to determine the safety, efficacy and potential risks of RNSM. Up to 12 RNSM will be performed to assess the safety and feasibility of the procedure. Routine follow-up visits and study assessments will occur at 14 days, 30 days, 6 weeks, 6 months and 12 months. The primary outcome is to assess the feasibility of removing the breast gland en bloc using the RNSM technique. To assess safety, postoperative complication information will be collected. Secondary outcomes include defining benefits and challenges of RNSM for both surgeons and patients using surveys, as well as defining the breast and nipple-areolar complex sensation recovery following RNSM. Mainly, descriptive analysis will be used to report the findings.Ethics and disseminationThe RNSM protocol was reviewed and approved by the US Food and Drug Administration using the Investigational Device Exemption mechanism (reference number G200096). In addition, the protocol was registered with ClinicalTrials.gov (NCT04537312) and approved by The Ohio State University Institutional Review Board, reference number 2020C0094 (18 August 2020). The results of this study will be distributed through peer-reviewed journals and presented at surgical conferences.Trial registration numberNCT04537312.

Surgical management of gynaecomastia by using cross chest liposuction and limited periareolar incision for gland excision: an interesting case report

Gynaecomastia is excessive or abnormal enlargement of male breast tissue. It is one of a common problem among young men. The term gynaecomastia means female like enlargement of male breast due to increase ductal tissue, stroma or fat. Most common cause of gynaecomastia is idiopathic. Surgical treatment of gynaecomastia involves liposuction and glandular excision and in few cases skin excision. Here author presents a case of 24 years old young healthy male with Simon’s grade 2B bilateral gynaecomastia. He had stubborn fat over bilateral chest which was resistant to exercise. Gynaecomastia was mixed type in characteristic having adipose tissue as well as glandular tissue enlargement. Bilateral liposuction and glandular excision by limited periareolar incision under general anesthesia as a day care procedure was done. In our procedure we used Cross chest liposuction. Patient was discharged at the same evening without any complications. After four months of follow up patient has male pattern chest with almost invisible scar and intact Nipple areolar complex (NAC) sensation.

Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients

Background Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes.Methods Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed.Results There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50–19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08–2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07–15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25–24.93; P=0.025).Conclusions Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

The Safety of Operating on Breasts With a History of Prior Reduction Mammoplasty: Dynamic Magnetic Resonance Imaging Analysis of Angiogenesis

Background Vascularity of the nipple-areolar complex (NAC) is altered after reduction mammoplasty, which increases complications risks after repeat reduction or nipple-sparing mastectomy. Objectives To evaluate angiogenesis of the NAC via serial analysis of breast magnetic resonance images (MRIs). Methods Breast MRIs after reduction mammoplasty were analyzed for 35 patients (39 breasts) using three-dimensional reconstructions of maximal intensity projection images. All veins terminating at the NAC were classified as internal mammary, anterior intercostal, or lateral thoracic in origin. The vein with the largest diameter was considered the dominant vein. Images were classified based on the time since reduction: <6 months, 6-12 months, 12-24 months, >2 years. Results The average number of veins increased over time: 1.17 (<6 months), 1.56 (6–12 months), 1.64 (12–24 months), 1.73 (>2 years). Within 6 months, the pedicle was the only vein. Veins from other sources began to appear at 6–12 months. In most patients, at least two veins were available after 1 year. After 1 year, the internal mammary vein was the most common dominant vein regardless of the pedicle used. Conclusions In the initial 6 months after reduction mammoplasty, the pedicle is the only source of venous drainage; however, additional sources are available after 1 year. The internal thoracic vein was the dominant in most patients. Thus, repeat reduction mammoplasty or nipple-sparing mastectomy should be performed ≥1 year following the initial procedure. After 1 year, the superior or superomedial pedicle may represent the safest option when the previous pedicle is unknown.

Management of Neurofibromatosis of the Nipple-Areolar Complex

Neurofibromatosis type 1 is an autosomal dominant disease having an incidence of 1 in 3000 individuals. It primarily involves the peripheral nervous system and usually presents with many neurofibromas. On rare occasions, NF1 can affect the breast and manifests as nipple-areolar complex extranipple (pseudopolythelia) like neurofibromas which can be disfiguring and sometimes cause pain and therefore need to be addressed surgically. We present a case of a 31-year-old female, who had multiple pedunculated neurofibromas around the nipple on both breasts for 3 years. These lesions were associated with mild pain and were increasing in size. Surgical excision was done while preserving the nipples bilaterally. NF1 primarily involves the peripheral nervous system and usually presents with a large number of neurofibromas. Several case series of patients with NF1 have been reported, but there are only a few published reports on neurofibromas of the nipple-areolar complexes. These lesions can be painful and cause cosmetic deformity. In our case, these lesions were approached by circumferentially excising the redundant nipple-areolar skin containing the neurofibromas, while isolating the nipple on a central ductal and vascular pedicle. In conclusion, the redundant nipple-areolar skin containing the neurofibromas can simply be approached by circumferential excision while preserving the nipple. This technique is simple, easy to perform, while it allows duct preservation and preserves cosmesis.

Treatment of large and ptotic breasts

The breasts have always been considered a sign of femininity. The correction of breast deformities is therefore important from a physical and psychological point of view, improving greatly the quality of life. Many surgical techniques have been proposed to correct the shape and volume of the breast, and in recent decades techniques have been proposed to preserve the nipple sensitivity and increase the vascular safety of the procedure. Templates (such as the Wise pattern) have been proposed to improve planning and different pedicles for the areola have been described. During the last 20 years, new techniques have been introduced to minimize scars, leaving normal sensitivity in almost all cases, the possibility of lactation, and a pleasing shape. The periareolar scar is, unfortunately, always necessary to reposition the nipple–areolar complex. The vertical scar is necessary to resect the excess of skin of the lower pole of the breast. Effort has been directed to reduce or eliminate the horizontal submammary scar, leading to a vertical scar only, even in large reductions.