Two breast cancer patients underwent single-port 3D E-NSM followed by immediate pedicled TRAM flap reconstruction at Changhua Christian Hospital (CCH) were reported. The medical records of the patients for breast cancer and cosmetic outcome were obtained. The study was approved by the Institutional Review Board of the CCH (CCH IRB No.:141224). The consent to use of clinical records was also obtained from each participant. The current study includes photos of two patients, and they agreed and signed the consent for publication of their pictures.
Clinical history
Case 1
A case of 42 year-old woman found one palpable right breast mass and enlarged axillary lymph nodes for 4 months. Breast ultrasonography revealed one mass with 4.6 X 2.5 cm in size at right breast 12’/3cm region and enlarged axillary lymph nodes, suspicious for metastases. Mammography showed right diffuse microcalcification. Core needle biopsy (CNB) revealed invasive ductal carcinoma (IDC) of breast and lymph node metastasis, grade 2, estrogen receptor(ER): positive (90%), progesterone receptor(PR):negative, Her2/neu: not overexpressed, Ki-67:10%. Magnetic Resonance Imaging (MRI) revealed multi-centric masses in right upper breast, about 6.1 cm in size, without nipple and skin invasion. Right axillary lymphadenopathy involving level I and II nodes were also recognized . Whole body survey showed no distant metastases. Neoadjuvant chemotherapy was suggested, but patient preferred and insisted surgery first.
Due to large (cup size E) & ptosis breast (Gr II), and post mastectomy radiotherapy indicated, TRAM flap reconstruction was recommended and she decided to received single port 3D E-NSM after shared decision making. A 6 cm axillary wound was created first, then axillary lymph node dissection (ALND) was performed. After completion of ALND, skin flap dissection under direct vision was performed for development of working space. Another 4cm length infra-mammary fold incision was created for facilitation of lower inner quadrant skin flap dissection and creation of tunnel for transposition of pedicled TRAM flap. After creation of working space and initial skin flap dissection, single-port 3D NSM was performed and intra-operative sub-nipple biopsy showed no invasion of malignant cells. The resected mastectomy specimen weight was 644 gm, then immediate pedicled TRAM flap reconstruction was performed. Contra-lateral Pedicled TRAM flap, about 750 gm in size, was selected due to post mastectomy radiotherapy indicated, and shifted to right breast after de-epithelialization. The total operation time was 521 mins, and blood loss was 200 ml. The post-operative recovery was uneventful except partial nipple ischemia/necrosis, which recovered spontaneous after 2 to 3 months of conservative wound care (Figure 3b & 3c).
The final pathological report revealed invasive carcinoma, mixed micropapillary and of no special type with mucinous differentiation, with tumor size 8-cm in size and 24 out of 28 lymph nodes metastases, pT3N3aM0 (anatomic stage IIIC, prognostic stage IIIA, AJCC 8th edition). She received adjuvant chemotherapy with docetaxel + cyclophosphamide x 4 cycles followed by epirubicin + cyclophosphamide x 4 cycles. Post mastectomy radiotherapy and endocrine therapy with letrozole were prescribed. No disease recurrence was observed after post operation 8 months follow-up.
Case 2
A 39 year-old female found one palpable mass over right breast for one month. She visited our CCH breast clinic for help, and sonography revealed one hypoechoic lesion about 13 X 10 mm in size at 10 o’clock/4 cm. CNB was performed, and pathologic report showed diffuse ductal carcinoma in situ (DCIS) with focal IDC, ER(+, 90%), PR(+, 80%), Her-2: not overexpressed, Gr II, and Ki-67: 10%. MRI revealed multi-focal mass, approximate 8.7 cm in size, without skin or nipple invasion and lymph node metastasis. Whole body survey showed no distant metastasis. NSM was suggested and she decided to receive IBR with pedicled TRAM flap due to obese abdomen and prior two Cesarean section histories. Single port 3D E-NSM was performed, and showed negative sentinel lymph node biopsy (SLNB) and sub-nipple biopsy. The resected mastectomy specimen weight was 570 gm (pre-operative breast size cup D, ptosis grade I), and IBR with ipsilateral pedicled TRAM flap, which weighted 650gm, was performed smoothly. The total operation time was 394 mins, and blood loss 170ml. The final pathological report revealed two focal tumors, with 19 X 15 mm and 14 X 11 mm in size, IDC of no special type and diffuse DCIS lesions. The pathological staging was T1cN0M0, stage IA. She received adjuvant chemotherapy with lipoxomal doxorubicin + cyclophosphamide x 4cyces, followed by endocrine therapy with GnRHa + Tamoxifen. The post-operative recovery was smooth, without nipple ischemia/necrosis or other wound related complications (Fig 3e & 3f). She remained disease free 7 months post operation.
Surgical Techniques of Singe port 3D E-NSM and IBR with pedicled TRAM flap.
Preoperative Marking
The infra-mammary fold, superior and lateral border of breast were identified and marked while patients were standing in upright position. The spindle-shaped incision mark of TRAM flap was designed for tension-free abdominal wound closure (Fig 2A).
Single-Port 3D videoscope assisted Endoscopic nipple sparing mastectomy (E-NSM)
Patient positioning
The technique of single port 3D E-NSM had been published in a short report[10], and we summarized as below. After general anesthesia, patients were put in supine position, and both arms were abducted 90 degree and the ipsilateral shoulder was elevated to 30o to facilitate the ongoing of surgery. The tumescent solution, containing lactated Ringer’s solution with lidocaine 0.05% and epinephrine 1:1000000, was injected subcutaneously into the whole breast to facilitate hydrodissection and reduce bleeding.
Surgical procedures
A 4-6 cm incision (depending on the size of breast to be removed) wound was placed over axillary or lateral chest at anterior axillary line area. Axillary lymph node surgery (SLNB or ALND) was performed first as indicated, then NSM was started by skin flap dissection. The skin flap dissection of upper and lower outer breast was done through the axillary or lateral chest wound as far as possible under direct vision with light retractor (Fig 1a). The lower inner breast skin flap dissection was performed through another 4 cm infra-mammary fold incision, which could also use for creation of tunnel between breast and TRAM flap. After creation of adequate working space, about 4cm in length, the single port (Glove Port, Nelis, Gyeonggi-do, Korea, Fig. 1b) could be inserted. The infra- mammary incision was closed temporarily by skin staple and covered by sterile plastic tap (OP-site) to prevent air leakage (Fig).
After single port (Figure 1b (G)) placement, carbon dioxide insufflation, which with air pressure set at 8 mmHg, was inflated to create space for subsequent skin flap dissection and mastectomy. A camera of 3D VIDEO Endoscope cam(30o) (Figure 1b (F)) was used during E-NSM. Dissection was done with laparoscopic curved Metzenbaum scissors (KARL STORZ) and laparoscopic grasping forceps (Figure 1b (B) & (A)). During skin flap dissection, a 30o upward facing 3D endoscope was turned into 30o downward by reversing 180o to give a clear 3D vision. The field of vision could be adjusted with either upward or downward by reverse of the 3D endoscope when necessary. Laparoscopic hook scissor (Figure 1b (C)) was used to transect the dense glandular tissue while dissecting beneath the nipple areolar complex (NAC) area. After total mastectomy, the sub-nipple biopsy of two separate specimens (inner and outer) was performed and sent for frozen section. If the NAC was invaded by cancer cell, the entire NAC was removed and skin-sparing mastectomy was performed instead.
Breast Reconstruction with TRAM Flap
Breast reconstruction with pedicled TRAM flap was performed after total mastectomy. The upper border of pedicled TRAM flap design was above umbilicus to harvest more rectus abdominis muscle perforators to increase flap survival, but the umbilicus was preserved. The contralateral or ipsilateral TRAM flap was performed per patient’ factor & doctor’ consideration. The flap harvest continued by elevating the flap with subcutaneous flap from lateral to medial until the lateral and medial margins of the rectus abdominis muscle were approached. The whole rectus abdominis muscle sheath remained intact to ensure blood supply.
The superior aspect of TRAM flap was harvested until the costal margin was reached (Figure 2f). At the inferior aspect of TRAM flap, the recuts muscle was transected at the level of preserving adequate perforator for perfusion of flap. During the recuts muscle transection, the deep inferior epigastric artery and vein were identified and ligated. At the posterior aspect of the TRAM flap, the posterior rectus sheath was separated from the preperitoneal fat and rectus myocutaneous flap was lifted up to the costal margin. The zone 1 and partial zone 2&3 (depends on the weight of the excised breast) of TRAM flap was preserved, and the superfluous tissue was removed (Fig 2f). The flap was de-epithelialized before transposition.
The subcutaneous tunnel was created from the infra-mammary fold incision from subcoastal margin to the mastectomy site. The TRAM flap was pulled through the tunnel to the mastectomy site. A Jackson-Pratt drain was placed in the mastectomy site, and another one placed in the axillary area if axillary lymph node surgery was performed. The axillary and infra-mammary wound were closed with 3-0 vicryl and 4-0 monocryl subcuticular sutures.
The defect of rectus abdominis muscle was approximated by using 3-0 prolene running sutures. Light weight mesh was used to cover the defect of rectus abdominis muscle and fixed by using 3-0 prolene interrupted sutures(Figure 2h). Two Jackson-Pratt drains were placed in the abdominal donor site. The patients were flexed to facilitate the donor site wound closure and assure the tension of donor site as less as possible. The new umbilicus position was located and the skin was removed for the umbilicus and then skin approximating by 4-0 monocryl. The donor site wounds were closed by approximating Camper and Scarpa fascia using 1-0 vicryl continuous sutures and skin closure using 3-0 vicryl and 4-0 monocryl running subcuticular sutures.
Postoperative results and aesthetic outcome
The post operation aesthetic results were recorded at the time of surgery and 3-month postoperative outpatient follow-up (Figure 2i, j & 3b, c, e, f). All these two patients were satisfied with the post-operative cosmetic outcome, and remained disease free.