title: Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts.
abstract: BACKGROUND
  Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications.
  
  
  METHODS
  Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple-areolar complex (NAC) on pathologic analysis, and cancer recurrence.
  
  
  RESULTS
  TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9%)], invasive cancer [301 breasts (45.8%)], and prophylactic risk-reduction [245 breasts (37.3%)]. A total of 210 patients (49%) had neoadjuvant chemotherapy, 78 (18.2%) had adjuvant chemotherapy, and 114 (26.7%) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7%) and invasive cancer in 9 breasts (1.4%); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2%) of partial nipple loss, 10 cases (1.5%) of complete nipple loss, and 78 cases (11.9%) of skin flap necrosis. Overall locoregional recurrence rate was 2% (median follow-up 28 months), with a 2.4% rate observed in the subset of patients with at least 3 years' follow-up (median 45 months). No NAC skin recurrences were observed.
  
  
  CONCLUSIONS
  In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, CA, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Warren Peled
authors.forename: Robert D
authors.initials: RD
authors.lastname: Foster
authors.forename: Allison C
authors.initials: AC
authors.lastname: Stover
authors.forename: Kaoru
authors.initials: K
authors.lastname: Itakura
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Ewing
authors.forename: Michael
authors.initials: M
authors.lastname: Alvarado
authors.forename: E Shelley
authors.initials: ES
authors.lastname: Hwang
authors.forename: Laura J
authors.initials: LJ
authors.lastname: Esserman
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000601:surgery* / Q000628:therapy; D002278:Carcinoma in Situ / Q000601:surgery* / Q000628:therapy; D018270:Carcinoma, Ductal, Breast / Q000601:surgery* / Q000628:therapy; D017024:Chemotherapy, Adjuvant; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology; D016462:Mammaplasty; D008408:Mastectomy / Q000009:adverse effects* / Q000379:methods; D008875:Middle Aged; D009336:Necrosis; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local / Q000209:etiology*; D018365:Neoplasm, Residual; D009558:Nipples / Q000098:blood supply / Q000473:pathology*; D059351:Organ Sparing Treatments; D018714:Radiotherapy, Adjuvant; D012086:Reoperation; D012867:Skin / Q000098:blood supply; D013524:Surgical Flaps / Q000473:pathology; D055815:Young Adult