title: Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes.
abstract: BACKGROUND
  Total skin-sparing mastectomy (TSSM) with preservation of the breast and nipple-areolar complex (NAC) skin was developed to improve aesthetic outcomes for mastectomy. Over time, indications for TSSM broadened and our technique has evolved with a series of systematic improvements.
  
  
  METHODS
  We reviewed all cases of TSSM with immediate breast reconstruction performed from 2005 to 2012. Patient comorbidities, treatment characteristics, postoperative complications, and outcomes were obtained prospectively and through medical chart review. Locoregional recurrences, distant recurrences, and patient survival were analyzed with Kaplan-Meier methods.
  
  
  RESULTS
  During this 8-year period, 633 patients (981 cases) underwent TSSM with median follow-up time of 29 (interquartile range 14-54) months. Immediate breast reconstruction was performed with tissue expander placement (89 %), pedicle TRAM (5 %), free flap (5 %), permanent implant (0.3 %), or latissimus flap (0.2 %). The incidences of postoperative complications decreased significantly over time. In 2012, these were down to 3.5 % for superficial nipple necrosis, 1.0 % for complete nipple necrosis, 3.0 % for minor skin flap necrosis, 4.4 % for major skin flap necrosis, 13.3 % for infections requiring oral antibiotics, 9.9 % for infections requiring intravenous antibiotics, 3.4 % for infections requiring operative intervention, and 8.5 % for expander/implant. Overall 5-year cumulative incidences of recurrence were 3.0 % (locoregional) and 4.2 % (distant), and there were no recurrences in the NAC skin.
  
  
  CONCLUSIONS
  Systematic changes in our technique of TSSM and immediate breast reconstruction have decreased postoperative complications over time. Oncologic outcomes of locoregional and distal recurrences remain similar to skin-sparing mastectomy techniques.
authors: Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA, frederick.wang@ucsfmedctr.org.
authors: Frederick
authors: F
authors: Wang
authors: Anne Warren
authors: AW
authors: Peled
authors: Elisabeth
authors: E
authors: Garwood
authors: Allison Stover
authors: AS
authors: Fiscalini
authors: Hani
authors: H
authors: Sbitany
authors: Robert D
authors: RD
authors: Foster
authors: Michael
authors: M
authors: Alvarado
authors: Cheryl
authors: C
authors: Ewing
authors: E Shelley
authors: ES
authors: Hwang
authors: Laura J
authors: LJ
authors: Esserman
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D009558:Nipples / Q000601:surgery; D059351:Organ Sparing Treatments; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D013524:Surgical Flaps; D015996:Survival Rate; D055815:Young Adult