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Background: Prosthetic breast reconstruction with prepectoral placement may confer clinical advantages compared with subpectoral placement. The purpose of this study was to assess and compare clinical outcomes following 2-stage reconstruction following prepectoral and partial subpectoral placement of tissue expanders and implants., Methods: A retrospective review of 39 (prepectoral) and 50 (partial subpectoral) patients was completed. Acellular dermal matrix was used in all patients. Mean age was 50.4 and 49.2 years, respectively. Body mass index (BMI) > 30 was noted in 15.4% of prepectoral and 18% of partial subpectoral patients. Radiation therapy was delivered to 38.5% of prepectoral patients and to 22% of partial subpectoral patients. Mean follow-up was 8.7 and 13 months for the prepectoral cohort and partial subpectoral cohorts., Results: The percentage of patients having at least 1 adverse event was 20.5% in the prepectoral and 22% in the partial subpectoral cohorts. The incidence of surgical-site infection and seroma was 8.1% and 4.8%, respectively, for the prepectoral cohort and 4.8% and 2.4%, respectively, for the partial subpectoral cohorts. Device explantation was 6.5% for the prepectoral and 7.2% for the partial subpectoral patients. Explantation did not occur in patients who had radiation or who had a BMI > 30. Four patients (6 breasts-7.2%) required conversion from partial subpectoral to prepectoral because of animation deformity., Conclusions: Prepectoral reconstruction is a viable alternative to partial subpectoral reconstruction. Proper patient selection is an important variable. Prepectoral reconstruction can be safely performed in patients with a BMI < 40 and in patients having postmastectomy radiation therapy.

Unlabelled: Biplanar oncoplastic surgery represents a novel technique with which to address partial breast reconstruction defects in small to medium sized breasts. Traditional oncoplastic volume displacement techniques may correct contour irregularities but do not address volumetric asymmetries. Volume replacement techniques classically rely on autologous tissue flaps. A biplanar approach, with a combination of glandular rearrangement techniques and volume enhancement with submuscular implants, can result in an alternative approach in select patients to achieve symmetry., Clinical Question/level of Evidence: Therapeutic, V.

Background: Nipple-sparing mastectomy remains controversial and its adoption has been slow because of oncologic and surgical concerns., Methods: A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactic indications for which records were available., Results: Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women. Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients. A subareolar biopsy specimen was taken in 39 of 49 breasts (80 percent); four (10 percent) revealed ductal carcinoma in situ, and the nipple or nipple-areola complex was later removed. Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised. With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex. The remaining 113 mastectomies (70 percent) were performed prophylactically on 80 patients. The subareolar tissue was biopsied in 80 breasts (71 percent). One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer. Two nipple-areola complexes (1.8 percent) were ischemic and excised. With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex., Conclusions: Nipple-sparing mastectomy can be safe in properly selected patients. A subareolar biopsy can effectively identify nipple-areola complexes that may harbor cancerous cells. Ischemic complications resulting in nipple loss can be minimized, and long-term follow-up suggests that this technique deserves further investigation in properly selected patients., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The debate over nipple-sparing mastectomy continues to evolve. Over the past several years, it has become more widely accepted, especially in the setting of prophylactic mastectomy, but its role in the treatment of breast cancer has only recently been reexamined., Methods: Two indications for the procedure are discussed: prophylactic, for the high-risk patient; and the more controversial topic, therapeutic nipple-sparing mastectomy, for the patient with breast cancer. A review of the literature suggests that certain breast cancers may be amenable to retaining the nipple if they meet specific oncologic criteria: tumor size 3 cm or less, at least 2 cm from the nipple, not multicentric, and with clinically negative nodes. Moreover, newer technologies such as magnetic resonance imaging and preoperative mammotome biopsy may make the procedure even safer in this setting. Practical and technical aspects of the procedure are discussed, including patient selection., Results: The accumulating data from multiple series of nipple-sparing mastectomy show that properly screened patients have a low risk of local cancer recurrence, that recurrences occur rarely in the nipple, and that recurrences in the nipple can be managed by removing the nipple., Conclusions: Despite continued controversy and the need for more long-term outcome data, nipple-sparing mastectomy is a procedure that is gaining increasing visibility and acceptance. Provided that certain oncologic and practical criteria are applied, it has the potential for allowing less invasive surgery and improved cosmetic outcomes without increased oncologic risk in appropriately selected patients.