|2009 Annual Meeting Abstracts
Preservation of the Nipple Areolar Complex: A Subjective and Objective Review of Aesthetic Outcomes Following Nipple-Sparing Mastectomy
Earl A. Gage, MD, James Gatherwright, MS IV, Sabrina Pavri, MS III, Steven Bernard, MD, Risal Djohan, MD.
Cleveland Clinic, Cleveland, OH, USA.
PURPOSE: To correlate patient satisfaction with aesthetic outcomes of the nipple-areolar complex (NAC) following nipple sparing mastectomy (NSM) with aesthetic assessment by objective observers.
METHODS: From 2001 to 2007, we performed NSM and immediate reconstruction on 141 patients. Following IRB approval, questionnaires were sent asking patients to rate their satisfaction with appearance, symmetry, color, position, sensation, function and texture of the NAC. We then asked which characteristics they would change and retrospective procedure choice. Three independent observers then reviewed the NAC in 34 consecutive photographed patients and rated the outcome with regard to appearance, color, symmetry and position.
RESULTS: We received completed surveys from 78 patients (55.3%). Mean patient age was 46.5 years (range 20 - 74). Mean follow-up was 50.4 months (range 9 - 100). Mean BMI was 24.2 (16.3 - 47.2). Average breast tissue removed was 398.16 grams(99 - 1096). Indications included 12 (15.4%) prophylactic and 66 (84.6%) documented tissue diagnoses. 40 (51.2%) were unilateral, and 38 (48.8%) were bilateral for a total of 116 operated breasts. Patient Responses. Appearance: 49 (62.8%) excellent; 7 (9.0%) good; 17 (21.8 %) fair; 5 (6.4%)poor. Symmetry: 44 (56.4%) excellent; 6 (7.7%) good; 18 (23.1%) fair; 10 (12.8%) poor. Color: 53 (67.9%) excellent; 10 (12.8 %) good; 11 (14.1%) fair; 4 (5.1%) poor. Position: 41 (52.6 %) excellent; 7 (9.0 %) good; 20 (25.6 %) fair; 10 (12.8 %) poor. Sensation: 6 (7.7%) excellent; 2 (2.6%) good; 23 (29.5%) fair; 47 (60.3%) poor. Arousal: 17 (21.8%) excellent; 4 (5.1%) good; 30 (38.5%) fair; 27 (34.6%) poor. Texture: 47 (60.3%) excellent; 6 (7.7%) good; 20 (25.6%) fair; 5 (6.4%) poor. If given the choice, 57 (73.1 %) indicated they would definitely have NSM again, 9 (11.5 %) “maybe, yes”, 5 (6.4 %) “maybe, no”, and 6 (7.6 %) “definitely no”. 82% indicated they would change at least one aspect of their result, 42.1 % would change more than one aspect. Among those who would change at least one aspect, 74.6 % would change sensation. Patients with larger volume of breast tissue removed (p=0.010), larger pre-operative body mass index(BMI) (p=0.034) or larger tissue expander fill volumes (p=0.007) reported lower satisfaction rate. Retrospective choice of NSM positively correlated with all questionnaire items except sensation and arousal. Patient assessments for appearance, color, symmetry and position correlated with those of objective observers. Observers rated NAC appearance, color, symmetry, and position as excellent or good in 68%, 78%, 62% and 66% of reviewed patients, respectively.
CONCLUSION: Our study is the largest series to address patient satisfaction with the NAC following NSM and the only one to positively correlate patient assessment with assessment by independent observers. Overall, patients were very satisfied with appearance of the NAC and a majority would choose NSM again. A majority of patients rated sensation as fair or poor, and sensation constituted the most frequent aspect of the NAC that patients would change. Larger BMI, expander fill volumes and volume of breast tissue removed may be predictive of dissatisfaction postoperatively.