|

Received: 25 September 2019    Accepted: 25 September 2019

DOI: 10.1111/tbj.13723

ORIGINAL ARTICLE

Collaboration between breast and reconstructive surgery in

optimizing outcomes for women with breast cancer

Risal Djohan MD | Rebecca Knackstedt MD, PhD

Department of Plastic Surgery, Cleveland

Clinic, Cleveland, Ohio
Correspondence
Risal Djohan, Department of Plastic Surgery,
Cleveland Clinic, 2049 E. 100 th Street, Mail
Code A60, Cleveland, OH 44195.
Email: djohanr@ccf.org
Abstract
Performing successful breast reconstruction after mastectomy requires communica-
tion and collaboration between the breast and reconstruction surgery teams. This
allows for oncologic safety while providing esthetic and functional reconstruction. In
this article, we discuss the numerous techniques we have adopted successfully into
our breast reconstructive practice that were possible due to this collaboration in-
cluding prophylactic lymphaticovenous bypass (LVB), tumor ultrasound-guided inci-
sion (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve
identification at time of mastectomy to allow for sensate reconstruction, and the
prevention of chronic pain and strategic oncoplasty.

KEYWORDS

breast cancer, collaboration, reconstructive surgery

1 |  I NTRO D U C TI O N reconstruction, and prevention of chronic pain and strategic

Successful breast reconstruction combines oncologic safety,
esthetic outcomes, patient satisfaction, and prevention of
chronic pain. At our major academic center, open communica-
tion and collaboration between the breast and reconstruction
surgeons allows for the development and refinement of surgical
approaches to optimize reconstructive success. As breast re-
construction involves the mastectomy and subsequent recon-
struction, often in one procedure, it is crucial that the breast and
plastic surgeon communicate preoperatively regarding surgical
incision, means of reconstruction and postoperative manage-
ment. In this article, we discuss the numerous techniques we
have adopted into our practices that were possible due to this
collaboration including prophylactic lymphaticovenous bypass
(LVB), tumor ultrasound-guided incision (TUGI), esthetic closure
in patients not eligible or desiring reconstruction, identification
of sensory nerves at time of mastectomy to allow for sensate
oncoplasty.
2 | LY M PH ATI COV E N O U S BY PA S S
Lymphedema is a potential complication following sentinel lymph
node biopsy (SNLB) and axillary lymph node dissection (ALND)
that is associated with both acute and chronic adverse effects.1,2
However, ALND remains a critical component of breast cancer treat-
ment with nodal involvement. There have been very few modifica-
tions in the surgical approach for ALND since its original description
by Halsted.3 Thus, the risk for the development of lymphedema after
ALND has remained relatively unchanged. Risk factors for develop-
ment of lymphedema include the number of nodes removed, obesity,
and radiation therapy.4 A recent meta-analysis of patients who un-
derwent ALND for breast cancer demonstrated a rate of postopera-
tive lymphedema ranging from 7% to 77%.5

Breast J. 2019;00:1–5. wileyonlinelibrary.com/journal/tbj© 2019 Wiley Periodicals, Inc.     1 |

 |
2       DJOHAN and KNACKSTEDT
Lymphaticovenous bypass (LVB) has shown to be viable treat-
ment option to treat or prevent lymphedema. LVB attempts to
divert lymphatic drainage that has been disrupted into a nearby
vein to allow for flow into the venous system. Therapeutic LVB is
performed after the development of lymphedema in an attempt
to reroute the lymph drainage into the venous system. A recent
meta-analysis identified 22 studies that reported on outcomes
after therapeutic LVB. Results demonstrated that 89% of patients
reported a subjective improvement, 88% experienced a quantita-
tive improvement, and 56% of patients were able to discontinue
6
compression therapy. As the success of LVB is largely dependent
on the ability of the surgeon to identify lymphatic channels, the
difficulty of this procedure increases in chronic lymphedema.7
However, LVB can also be performed at the time of mastectomy
to prevent the development of lymphedema. This can be aided
with axillary reverse mapping (ARM) at the time of ALND. ARM
involves injection of a dye or radioactive substance into the arm
at time of the ALND to highlight the lymphatic drainage pattern of
the limb. 5,8-10 It has been demonstrated that there is approximately
a 3% crossover rate between nodes draining the arm and those
draining the breast.10 While some reported that nodes identified
9,11,12
with ARM were free of metastatic cells ; others we demon-
strated metastatic cells in the nodes.13 An alternative option is to
remove the nodes but retain the lymphatic channels draining the
arm. This allows for preservation of arm afferent lymph channels
and does not require nodal preservation.
To perform ARM and LVB at time of mastectomy, collabora-
tion between the breast and reconstructive surgeon is required as
the breast surgeon must identify and preserve lymphatic channels
draining the arm at the time of nodal dissection. To begin, 3 cc of
isosulfan blue dye is injected approximately 6 cm distal to the axilla
in 4-6 evenly spaced aliquots in a linear band. The injection site is
massaged with the arm elevated for 1 minute. ALND is performed
using loupe magnification and minimal cautery dissection. Blue-
stained lymph nodes outside the axillary resection borders are pre-
served and unassociated lymphatic channels are left in-continuity.
Veins and small tributaries are carefully preserved. After ALND, the
lymphatic architecture is assessed. Transected, blue dye-contain-
ing lymphatics are mobilized and target veins are identified and as-
sessed for size match, proximity to lymphatic structures, excursion,
and valvular competency. For precise size match and the availability
of a single transected lymphatic, we employee an end-to-end micro-
anastomotic. When there is significant size discrepancy, or if there
are multiple transected lymphatics in proximity to a recipient vein,
we use an intussusception technique. If blue dye is visualized tra-
versing the LVB anastomosis, the coaptation is deemed patent. ICG
can be injected into the dorsal webspaces of the hand to allow for
confirmation of patency.
Our institution currently offers both therapeutic and prophy-
lactic LVB. Collaboration with the physical therapy department ad-
ditionally allows for preoperative optimization of lymphedema for
patients undergoing therapeutic LVB and the teaching of preven-
tative strategies to patients undergoing prophylactic LVB. We are
following our patients prospectively to determine the efficacy of our
multi-disciplinary approach.
3 | T U M O R U LTR A S O U N D - G U I D E D
INCISION
For selected individuals, nipple sparing mastectomy (NSM) permits
oncologic safety while optimizing esthetic results.14-16 Initial concerns
for cancer recurrence in NSM 17-19 have largely been mitigated. 20-30
NSMs can be performed through a variety of incisions.14,24,31,32 An
inframammary (IMF) incision is often utilized which can make it
difficult to reach the upper quadrant of the breast.31-34 By using a
tumor ultrasound-guided incision (TUGI), a NSM can be offered to
patients who may have otherwise been ineligible. Our department
previously reported on our oncologic outcomes utilizing a tumor
ultrasound-guided incision (TUGI) to allow for NSM. The approach
was performed in 13 patients over a 3-year period. All patients who
underwent TUGI had tumors that fit established guidelines for NSM,
but the tumor was close to the skin or in a region of the breast that
was not conducive to a NSM. The incision was made collaboratively
with the plastic surgeon to allow for reconstruction while ensuring
oncologic safety. Core biopsies of the nipple were routinely per-
formed, and SLNB was performed when appropriate through the
same or a different axillary incision.35 This approach allowed for
placement of tissue expanders or implants, with or without acellular
dermal matrix, and did not affect final reconstructive outcome. At
three-year follow-up, there were no instances of local recurrence,
thus demonstrating the oncologic safety of this approach.35
4 | M A S TEC TO M Y C LOS U R E I N N O N -
R ECO N S TRU C TI V E PATI E NT S
Not all women pursue post-mastectomy reconstruction due to medi-
cal comorbidities or personal preferences. While significant atten-
tion has been paid to optimizing the results of breast reconstruction,
much less attention has been given to mastectomy closure in women
who do not desire reconstruction. Achieving a “flat” closure can be
a challenge, even for experienced surgeons, particularly in patients
with a large breast size or high body mass index. When post-mastec-
tomy reconstruction is not pursued, the soft tissue and skin closure
may be performed by the breast surgeon or with the assistance of a
plastic surgeon.
Our department applied lessons learned from a double incision
female-to-male mastectomy (FTTM) to this patient population, as
postoperative goals are similar with the removal of breast tissue with
a postoperative esthetically pleasing breast concavity. Common rea-
sons to pursue revisionary surgery in FTTM with a double incision
include surgical dog-ears and residual axillary tissue.36,37 These are
also concerns in women undergoing mastectomy without recon-
struction. Additionally, women with higher BMIs have a postopera-
tive transition from a concave chest to convex epigastric region that
DJOHAN and KNACKSTEDT
is stigmatizing for having undergoing a mastectomy. To determine
the most esthetic approach to perform post-mastectomy closure
without reconstruction, we performed cadaveric dissections and
applied the approaches and principles to patients with success.
Preoperatively, the discussion is had with the patient to deter-
mine whether she desires to be completely flat or desires some bulk
in order to allow for the appearance of a small breast. Patients with
B or smaller breasts may not adequate remaining tissue to allow for
tissue rearrangement to create a new “breast mound.” It is prudent
to counsel these patients on the challenges of this surgery and ex-
pected outcomes. Further, it is important to discuss the potential
need for additional revision procedures to achieve the desired cos-
metic outcome.
The surgical approach varies based on the patient's preopera-
tive breast size, shape, degree of ptosis, and goals for reconstruc-
tion. For women with a B cup or smaller breasts, the skin-sparing
mastectomy can generally be performed with a simple elliptical
excision and closure. Any excess axillary tissue can be removed
with a lateral extension to the incision. This permits a flat, es-
thetically pleasing closure. However, women with larger, more
ptotic breasts require local tissue rearrangement to allow for a
flat closure or to permit the creation of a breast mound. For these
women, once the breast is removed, the cranial mastectomy flap
is allowed to overlap the caudal mastectomy flap to determine tis-
sue redundancy. To prevent concavity in the epigastric region, the
redundant caudal flap is de-epithelialized to allow for some bulk.
Once this is completed, with the cranial flap overlying the caudal
flap, excess tissue in the horizontal plane is assessed. If the pa-
tient desires a flat reconstruction, the incision is closed. However,
if the patient desires a small breast mound, excess axillary, non-
breast tissue can be medialized to provide bulk. Excess skin in the
horizontal plane is removed with a small lateral incision similar to
a Wise-pattern closure. If a patient desires a flat reconstruction,
more tissue can be removed at this point or residual tissue can be
maintained to create a small breast mound.
This technique addresses the aforementioned concerns by taking
into account tissue in the horizontal and lateral planes. As opposed
to simply discarding these tissues, they are utilized to contribute
bulk to the reconstruction and provide the natural contour observed
with a small breast, if desired. If a women desires to be completely
flat without any semblance of a breast, we do not utilize as much of
the excess horizontal and lateral tissue, rather just enough to smooth
the transition from the chest to the epigastric region over the intra-
mammary fold (in press).
5 | N I PPLE S PA R I N G M A S TEC TO M Y W ITH
N E RV E I D E NTI FI C ATI O N FO R S E N SATE
R ECO N S TRU C TI O N
With improvements in surgical management, increasing amounts
38,39
of the native breast skin can be spared with oncologic safety.
This has improved esthetic outcomes, but it does not affect the
|
      3
loss of sensation in the breast. The innervation of the breast and
nipple areolar complex (NAC) has been well described, with the
dominant innervation originating from the medial and lateral cu-
taneous branches of the third to fifth intercostal nerves. These
branches are routinely included with the mastectomy 40,41 and the
amount of sensation that can be retained or regenerated post-
mastectomy varies widely in the literature.42-48 Thus, patients
have decreased protective and erogenous sensation of the breast
post-mastectomy and reconstructions are susceptible to seem-
ingly innocuous insults.49-53
The concept of providing neurotized autologous breast recon-
struction is not novel, but the introduction of cadaveric nerve grafts
has allowed for the development of new techniques and a resur-
gence in academic interest. To date, the majority of studies in sen-
sate breast reconstruction have utilized the 3rd to 7th anterior or
lateral intercostal nerves as the breast donor nerve.54,55 Our depart-
ment published a cadaveric study characterizing the location of the
lateral intercostal nerve at the lateral 4th intercostal space to allow
for ease of dissection of this nerve.56
Due to our close relationship with the breast surgery team, we
have begun a collaboration that involves identification and pres-
ervation of the lateral 4th intercostal nerve at the time of nipple
sparing mastectomy. This nerve has then been utilized to perform
sensate implant-based reconstruction. Patients with a size C breast
or smaller are appropriate candidates for this approach as larger
breasts would require a longer nerve graft. The nerve is dissected to
preserve as much length as possible to decrease the length of nerve
graft that is required. Once the nerve has been isolated and pre-
served, a processed nerve graft is utilized as an interpositional graft
connecting the donor 4th intercostal nerve to the targeted NAC. The
coaptation of the native donor nerve to the nerve graft is usually
performed under operating microscope or loupe magnification using
8.0 or 9.0 nylon suture. A nerve connector is commonly utilized to
avoid coaptation under tension.
The tissue expander or implant is placed as a pre-pectoral or
sub-pectoral breast reconstruction. The nerve graft is anchored to
the underside of the NAC with 5-0 Prolene sutures.
We plan on monitoring the return of breast sensation in these
patients as we continue to perform this procedure. We also plan
on determining the impact that enabling potentially faster, more
reproducible breast sensations has on breast-related quality of life.
6 | M A S TEC TO M Y W ITH N E RV E
I D E NTI FI C ATI O N FO R PR E V E NTI O N O F
C H RO N I C PA I N
Chronic pain following mastectomy, with a reported incidence up
to 60%, has a detrimental impact on quality of life.57 Treatments
for chronic neuropathic pain have varied efficacy and typically re-
quire long-term pharmacologic therapy.58 Due to our knowledge of
the location of the lateral fourth intercostal nerve, when patients
presented with localized pain that originated from this location, we
 |
4       DJOHAN and KNACKSTEDT
hypothesized that a transected nerve from the time of mastectomy
was responsible. Thus, we initiated a targeted breast re-innervation
(TBR) protocol to address this cause of chronic pain with success.59
However, if this nerve can be isolated and preserved at time of
mastectomy by the breast surgeon, the likelihood of this source of
chronic pain greatly diminishes. By performing cadaver dissections
with our breast team and demonstrating the nerve in patients after
mastectomy, the breast surgeons were empowered to preserve this
nerve during their dissection.
7 |  S TR ATEG I C O N CO PL A S T Y
Oncoplastic reduction, or oncoplasty, aims to allow for oncologic
clearance combined with the esthetics of a breast reduction. For
some women, this involves resection of a large section of the
breast. Additionally, postoperative radiation therapy impacts the
final contour and size of the breast. It has been reported that up
to 30% of patients who undergone breast conservation therapy
have suboptimal esthetic outcomes. 60,61 As numerous pedicles
and skin resection patterns have been described for oncoplasty,
communication between the breast and plastic surgeon is critical.
Collaboration preoperatively allows for an accurate prediction by
the breast surgeon regarding resection volume and area of exci-
sion to facilitate planning by the plastic surgeon. 62 Additionally,
this allows for appropriate preoperative discussions with the pa-
tient to set realistic expectations, discuss possible procedures for
symmetry and potential pitfalls.
8 |  CO N C LU S I O N
In conclusion, to optimize surgical results, collaboration is required
between the breast and plastic surgeon. This relationship and com-
munication allow for oncologically safe and esthetically pleasing re-
constructive results.
ORCID
Rebecca Knackstedt  https://orcid.org/0000-0003-0961-4378
REFERENCES
1. de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity
after inguinal sentinel lymph node biopsy and completion lymph
node dissection in patients with cutaneous melanoma. Eur J Surg
Oncol. 2006;32:785-789.
2. Hyngstrom JR, Chiang YJ, Cromwell KD, et al. Prospective assess-
ment of lymphedema incidence and lymphedema-associated symp-
toms following lymph node surgery for melanoma. Melanoma Res.
2013;23:290-297.
3. Halsted WSI. The results of operations for the cure of cancer of the
breast performed at the Johns Hopkins Hospital from June, 1889,
to January, 1894. Ann Surg. 1894;20:497-555.
4. Rebegea L, Firescu D, Dumitru M, Anghel R. The incidence and
risk factors for occurrence of arm lymphedema after treatment of
breast cancer. Chirurgia (Bucur). 2015;110:33-37.
5. Thompson M, Korourian S, Henry-Tillman R, et al. Axillary reverse
mapping (ARM): a new concept to identify and enhance lymphatic
preservation. Ann Surg Oncol. 2007;14:1890-1895.
6. Basta MN, Gao LL, Wu LC. Operative treatment of peripheral
lymphedema: a systematic meta-analysis of the efficacy and safety
of lymphovenous microsurgery and tissue transplantation. Plast
Reconstr Surg. 2014;133:905-913.
7. Silva AK, Chang DW. Vascularized lymph node transfer and lym-
phovenous bypass: novel treatment strategies for symptomatic
lymphedema. J Surg Oncol. 2016;113:932-939.
8. Nos C, Lesieur B, Clough KB, Lecuru F. Blue dye injection in the arm
in order to conserve the lymphatic drainage of the arm in breast
cancer patients requiring an axillary dissection. Ann Surg Oncol.
2007;14:2490-2496.
9. Boneti C, Korourian S, Bland K, et al. Axillary reverse mapping:
mapping and preserving arm lymphatics may be important in pre-
venting lymphedema during sentinel lymph node biopsy. J Am Coll
Surg. 2008;206(5):1038-1042; discussion 1042-4.
10. Klimberg VS. A new concept toward the prevention of lymph-
edema: axillary reverse mapping. J Surg Oncol. 2008;97:563-564.
11. Casabona F, Bogliolo S, Ferrero S, et al. Axillary reverse mapping
in breast cancer: a new microsurgical lymphatic-venous pro-
cedure in the prevention of arm lymphedema. Ann Surg Oncol.
2008;15:3318-3319.
12. Boccardo F, Casabona F, De Cian F, et al. Lymphedema microsur-
gical preventive healing approach: a new technique for primary
prevention of arm lymphedema after mastectomy. Ann Surg Oncol.
2009;16:703-708.
13. Ponzone R, Mininanni P, Cassina E, Sismondi P. Axillary reverse
mapping in breast cancer: can we spare what we find? Ann Surg
Oncol. 2008;15(1):390-391.
14. Rossi C, Mingozzi M, Curcio A, et al. Nipple areola complex sparing
mastectomy. Gland Surg. 2015;4:528-540.
15. Benson JR, Dumitru D, Malata CM. Oncologic safety of conservative
mastectomy in the therapeutic setting. Gland Surg. 2016;5:37-46.
16. Laronga C, Smith P. Nipple-sparing mastectomy: an oncologic and
cosmetic perspective. Surg Oncol Clin N Am. 2014;23:549-566.
17. Menon RS, van Geel AN. Cancer of the breast with nipple involve-
ment. Br J Cancer. 1989;59:81-84.
18. Verma GR, Kumar A, Joshi K. Nipple involvement in peripheral
breast carcinoma: a prospective study. Indian J Cancer. 1997;34:1-5.
19. Vyas JJ, Chinoy RF, Vaidya JS. Prediction of nipple and areola in-
volvement in breast cancer. Eur J Surg Oncol. 1998;24:15-16.
20. Warren Peled A, Foster RD, Stover AC, et al. Outcomes after total
skin-sparing mastectomy and immediate reconstruction in 657
breasts. Ann Surg Oncol. 2012;19:3402-3409.
21. Piper M, Peled AW, Foster RD, et al. Total skin-sparing mastectomy:
a systematic review of oncologic outcomes and postoperative com-
plications. Ann Plast Surg. 2013;70:435-437.
22. Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy
for prophylactic and therapeutic indications. Plast Reconstr Surg.
2011;128:1005-1014.
23. Endara M, Chen D, Verma K, et al. Breast reconstruction following
nipple-sparing mastectomy: a systematic review of the literature
with pooled analysis. Plast Reconstr Surg. 2013;132:1043-1054.
24. Munhoz AM, Montag E, Filassi JR, et al. Immediate nipple-are-
ola-sparing mastectomy reconstruction: an update on on-
cological and reconstruction techniques. World J Clin Oncol.
2014;5:478-494.
25. Crowe Jr JP, Kim JA, Yetman R, et al. Nipple-sparing mastectomy:
technique and results of 54 procedures. Arch Surg. 2004;139:148-150.
26. Rusby JE, Brachtel EF, Taghian A, Michaelson JS, Koerner FC,
Smith BL. George Peters Award. Microscopic anatomy within the
nipple: implications for nipple-sparing mastectomy. Am J Surg.
2007;194:433-437.
DJOHAN and KNACKSTEDT
27. Stanec Z, Zic R, Stanec S, et al. Skin-sparing mastectomy with nip-
ple-areola conservation. Plast Reconstr Surg. 2003;111(1):496-498.
28. Palmieri B, Baitchev G, Grappolini S, et al. Delayed nipple-spar-
ing modified subcutaneous mastectomy: rationale and technique.
Breast J. 2005;11:173-178.
29. Benediktsson KP, Perbeck L. Survival in breast cancer after nip-
ple-sparing subcutaneous mastectomy and immediate recon-
struction with implants: a prospective trial with 13 years median
follow-up in 216 patients. Eur J Surg Oncol. 2008;34:143-148.
3 0. Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy
in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol.
2011;18:1665-1670.
31. Stolier AJ, Sullivan SK, Dellacroce FJ. Technical considerations in
nipple-sparing mastectomy: 82 consecutive cases without necrosis.
Ann Surg Oncol. 2008;15:1341-1347.
32. Rawlani V, Fiuk J, Johnson SA, et al. The effect of incision choice on
outcomes of nipple-sparing mastectomy reconstruction. Can J Plast
Surg. 2011;19:129-133.
33. Agrawal A, Sibbering DM, Courtney C-A. Skin sparing mastectomy
and immediate breast reconstruction: a review. Eur J Surg Oncol.
2013;39:320-328.
3 4. Blechman KM, Karp NS, Levovitz C, et al. The lateral inframam-
mary fold incision for nipple-sparing mastectomy: outcomes from
over 50 immediate implant-based breast reconstructions. Breast J.
2013;19:31-40.
35. Fernando EJ, Eskenazi BR, Djohan RS, et al. A tumor ultra-
sound-guided incision (TUGI) approach to nipple-sparing mas-
tectomy: balancing oncologic safety and technical outcomes. Clin
Breast Cancer. 2017;17:572-577.
36. Frederick MJ, Berhanu AE, Bartlett R. Chest surgery in female to
male transgender individuals. Ann Plast Surg. 2017;78:249-253.
37. Frey JD, Yu JZ, Poudrier G, et al. Modified nipple flap with free
areolar graft for component nipple-areola complex construction:
outcomes with a novel technique for chest wall reconstruction in
transgender men. Plast Reconstr Surg. 2018;142:331-336.
38. Crowe JP, Patrick RJ, Yetman RJ, et al. Nipple-sparing mastectomy
update: one hundred forty-nine procedures and clinical outcomes.
Arch Surg. 2008;143:1106-1110; discussion 1110.
39. Grobmyer SR, Pederson HJ, Valente SA, et al. Evolving indications
and long-term oncological outcomes of risk-reducing bilateral nip-
ple-sparing mastectomy. BJS Open. 2019;3:169-173.
4 0. Sarhadi NS, Shaw Dunn J, Lee FD, et al. An anatomical study of the
nerve supply of the breast, including the nipple and areola. Br J Plast
Surg. 1996;49:156-164.
41. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nip-
ple-areola complex: an anatomic study. Plast Reconstr Surg.
2000;105:905-909.
42. Tairych GV, Kuzbari R, Rigel S, et al. Normal cutaneous sensibility of
the breast. Plast Reconstr Surg. 1998;102:701-704.
43. Harbo SO, Jørum E, Roald HE. Reduction mammaplasty: a prospec-
tive study of symptom relief and alterations of skin sensibility. Plast
Reconstr Surg. 2003;111(1):103-110; discussion 111–2.
4 4. Frost MH, Schaid DJ, Sellers TA, et al. Long-term satisfaction and
psychological and social function following bilateral prophylactic
mastectomy. JAMA. 2000;284:319-324.
45. Pitanguy I, Vaena M, Radwanski HN, et al. Relative implant volume
and sensibility alterations after breast augmentation. Aesthetic Plast
Surg. 2007;31:238-243.
|
      5
46. Craig RD, Sykes PA. Nipple sensitivity following reduction mamma-
plasty. Br J Plast Surg. 1970;23:165-172.
47. Kuzbari R, Schlenz I. Reduction mammaplasty and sensitivity of the
nipple-areola complex: sensuality versus sexuality? Ann Plast Surg.
2007;58:3-11.
48. Temple CL, Hurst LN. Reduction mammaplasty improves breast
sensibility. Plast Reconstr Surg. 1999;104:72-76.
49. Mahajan AL, Chapman TW, Mandalia MR, et al. Sun burn as a conse-
quence of resting reading glasses on a reconstructed breast. J Plast
Reconstr Aesthet Surg. 2010;63:e170.
50. Kay AR, McGeorge D. Susceptibility of the insensate reconstructed
breast to burn injury. Plast Reconstr Surg. 1997;99:927.
51. Gowaily K, Ellabban MG, Iqbal A, et al. Hot water bottle burn to
reconstructed breast. Burns. 2004;30:873-874.
52. Nahabedian MY, McGibbon BM. Thermal injuries in autogenous tis-
sue breast reconstruction. Br J Plast Surg. 1998;51:599-602.
53. Enajat M, Rozen WM, Audolfsson T, et al. Thermal injuries in the
insensate deep inferior epigastric artery perforator flap: case se-
ries and literature review on mechanisms of injury. Microsurgery.
2009;29:214-217.
54. Weissler JM, Koltz PF, Carney MJ, et al. Sifting through the evi-
dence: a comprehensive review and analysis of neurotization in
breast reconstruction. Plast Reconstr Surg. 2018;141:550-565.
55. Beugels J, Cornelissen AJM, Spiegel AJ, et al. Sensory recovery of
the breast after innervated and non-innervated autologous breast
reconstructions: a systematic review. J Plast Reconstr Aesthet Surg.
2017;70:1229-1241.
56. Knackstedt R, Gatherwright J, Cakmakoglu C, et al. Predictable
location of breast sensory nerves for breast reinnervation. Plast
Reconstr Surg. 2019;143:393-396.
57. Andersen KG, Kehlet H. Persistent pain after breast cancer treat-
ment: a critical review of risk factors and strategies for prevention.
J Pain. 2011;12:725-746.
58. Hatch MN, Cushing TR, Carlson GD, et al. Neuropathic pain and
SCI: Identification and treatment strategies in the 21st century. J
Neurol Sci. 2018;384:75-83.
59. Gatherwright J, Knackstedt R. Targeted breast re-innervation
(TBR) for post-mastectomy pain. J Plast Reconstr Aesthet Surg.
2019;72(10):1700-1738.
60. Clough KB, Cuminet J, Fitoussi A, et al. Cosmetic sequelae after
conservative treatment for breast cancer: classification and results
of surgical correction. Ann Plast Surg. 1998;41:471-481.
61. D'Aniello C, Grimaldi L, Barbato A, et al. Cosmetic results in 242
patients treated by conservative surgery for breast cancer. Scand J
Plast Reconstr Surg Hand Surg. 1999;33:419-422.
62. Chang MM, Huston T, Ascherman J, et al. Oncoplastic breast reduc-
tion: maximizing aesthetics and surgical margins. Int J Surg Oncol.
2012;2012:907576.
How to cite this article: Djohan R, Knackstedt R.
Collaboration between breast and reconstructive surgery in
optimizing outcomes for women with breast cancer. Breast J.
2019;00:1–5. https​://doi.org/10.1111/tbj.13723​