Comparative study of layered breast defect reconstruction and traditional surgery in the treatment of plasma cell mastitis: a single-center study

Introduction

Plasma cell mastitis (PCM) is a rare, chronic inflammatory breast disease primarily affecting women of reproductive age (1,2). It is characterized by plasma cell infiltration in breast tissue and commonly presents as a painful breast mass, nipple discharge, or erythema (3,4). Despite its benign nature, PCM often mimics breast cancer both clinically and radiologically, posing diagnostic challenges (5). Surgical treatment, such as segmental mastectomy, is typically required when conservative management fails (6,7). Although surgical excision has become the mainstream treatment method, the high postoperative recurrence rate cannot be ignored (8). Patients may experience breast asymmetry, scarring, and dissatisfaction, which negatively affect their quality of life (9). Therefore, there is a pressing need for a treatment strategy that offers both clinical efficacy and satisfactory aesthetic outcomes.

Recent advances have explored various reconstructive and minimally invasive techniques to address these issues. For instance, continuous postoperative negative pressure irrigation assisted mammaplasty may have effect in the treatment chronic refractory PCM (10). However, this method may cause considerable physical discomfort to patients. More recently, ultrasound-guided microwave ablation has been reported as an emerging technique for PCM treatment, with results suggesting superior efficacy compared to traditional surgery (11). Nevertheless, the clinical evidence remains limited due to small sample sizes, short follow-up durations, and a lack of pathophysiological rationale supporting its use in mastitis treatment.

In the field of breast cancer surgery, the use of internal tissue flaps to reduce dead space following tumor excision has been shown to improve postoperative cosmetic outcomes (12). While this technique is commonly employed in the treatment of malignant breast tumors, their application in PCM has not yet been reported.

We integrated layered breast defect reconstruction (LBDR) into the treatment of PCM. LBDR applies simplified, standardized oncoplastic principles to compensate for tissue loss and restore breast contour through internal glandular advancement and layered fat redistribution. This technique reduces dead space, maintains breast projection, and enhances cosmetic outcomes. Importantly, LBDR does not require advanced oncoplastic training; it is easy to learn and reproducible, offering a practical option for general surgeons aiming to achieve both disease control and breast preservation in PCM management. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-99/rc).

Methods

Study population

This retrospective study enrolled female patients diagnosed with PCM who received surgical treatment at the Third Medical Center of the Chinese PLA General Hospital between January 2002 and January 2018. Inclusion criteria were: female patients; postoperative pathological results confirming PCM; patients undergoing segmental mastectomy of at least one quadrant without any prior breast surgery; complete follow-up data; normal liver and kidney function, blood sugar levels, complete blood count, and coagulation function before surgery; and small residual breast area with significant gaps. The exclusion criteria were: male patients; history of similar breast disease surgery; history of malignant tumors, chemotherapy, and chest radiotherapy; history of chest surgery; pregnant or breastfeeding patients; history of tuberculosis; and patients with breast cancer opting for breast-conserving surgery. Based on the defined inclusion and exclusion criteria, a total of 90 eligible patients were enrolled in the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Third Medical Center of Chinese PLA General Hospital (No. KY2002-020). Individual consent for this retrospective analysis was waived.

Data collection

Clinical data were collected, and the age, treatment history, preoperative disease course, local symptoms and related risk factors in patients with PCM were recorded. The follow-up duration was from the date of PCM diagnosis to the date of the last review. Recurrence was defined as the reappearance of symptoms such as breast pain, palpable masses, or localized erythema in the same region or other quadrants of the ipsilateral breast. All patients underwent routine follow-up for a period of more than three years. Follow-up was conducted through outpatient visits and telephone review.

LBDR

After complete removal of the lesion, if there is a defect area (Figure 1A), tissue flaps are harvested based on the preoperative ultrasound estimation of the thickness of the fat and glandular layers. According to the structural layers, a part of the distal fat flap is selected and cut to an appropriate size for filling, then rotated and transferred, with its distal part fixed to the chest wall (Figure 1B). Similarly, a proximal glandular flap from the lower-inner side of the nipple is harvested, rotated, and its distal part fixed to the superficial layer of the pectoral muscle fascia, then sutured to the upper glandular layer (Figure 1C). Additionally, some fat tissue is collected from the lower-inner quadrant and fixed behind the nipple to support it (Figure 1D), followed by step-by-step suturing (Figure 1E).

Figure 1 Step-by-step process of layered breast defect reconstruction. (A) Defect area after lesion removal; (B) harvesting tissue flaps based on preoperative ultrasound estimation; (C) rotating and securing the proximal glandular flap to the pectoral muscle fascia and upper glandular layer; (D) supporting the nipple with fat tissue from the lower-inner quadrant; (E) final step-by-step suturing for tissue integration.

Breast appearance evaluation criteria

The postoperative breast appearance evaluation criteria were categorized into three levels: excellent, good, and poor. Excellent indicated that the breasts were completely symmetrical, with a nipple level difference ≤2 cm, no difference to touch, and the affected breast appeared normal compared to the other side, with no scars causing breast uplift or deformation. The surgical scar was not obvious, and patient satisfaction was high. Good indicated that the breasts were basically symmetrical, with a nipple level difference ≤2 cm. There were visible skin scars and a slight difference to touch compared to the other side. Patient satisfaction was average. Poor indicated that the breasts were completely asymmetrical, with a nipple level difference >2 cm. The touch was poor, and the surgical scar was obvious, with local depressions or deformities. Patient satisfaction was poor. The poor category was classified as the ineffective repair group, while the good and excellent categories were considered the effective repair group.

Statistical analysis

All statistical analyses were conducted using R software, with a two-sided significance threshold set at P<0.05. The Kolmogorov-Smirnov test was applied to assess the normality of continuous variables. Categorical data were summarized as frequencies and percentages, while normally distributed continuous variables were reported as mean ± standard deviation. For comparisons between groups, the independent samples t-test was employed under conditions meeting parametric assumptions. Associations between categorical variables were evaluated using the chi-squared test. Logistic regression was used to calculate odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Variables that demonstrated a significant association with recurrence (P<0.05) in univariate analyses were subsequently included in the multivariate logistic regression model.

Results

Ninety patients with PCM who underwent surgical treatment were enrolled in this study (Table 1). The onset age was 16–47 years, the mean age was 30 [26–34] years, with an median body mass index (BMI) of 24.3 [22.4–26.77] kg/m². Eight patients (9%) had a history of smoking, and nine (10%) had a history of breast trauma. The most common complaint was a breast mass (86 cases, 96%), and 66 patients (73%) had a history of breastfeeding. There were 14 patients (16%) with nipple discharge, and 41 (46%) with nipple depression. The lesions were located as follows: 26 in the upper inner quadrant, 14 in the lower inner quadrant, 34 in the upper outer quadrant, and 16 in the lower outer quadrant.

Sixty-six patients (73%) underwent LBDR, while 24 (27%) underwent traditional surgery. Baseline characteristics of the two groups are presented in Table 1. There were no significant differences between the LBDR and traditional surgery groups in terms of BMI, history of smoking, history of breastfeeding, nipple discharge, nipple depression, breast redness, swelling, and mass, breast trauma, rupture, and autoimmune diseases. However, patients in the LBDR group were significantly older compared to those in the traditional surgery group (P=0.003). Additionally, significant differences in lesion locations were observed between the groups (P=0.02): upper inner quadrant (35% vs. 12%), lower inner quadrant (9% vs. 33%), upper outer quadrant (36% vs. 42%), and lower outer quadrant (20% vs. 12%).

We further assessed the impact of LBDR on postoperative breast appearance. Compared to the traditional surgery group, patients in the LBDR group demonstrated significantly higher breast appearance scores (98.48% vs. 8.33%, P<0.001) (Table 2). Univariable logistic regression analysis revealed that LBDR (OR =0.00, 95% CI: 0.00–0.02, P=0.001) and older age (OR =0.90, 95% CI: 0.82–0.98, P=0.015) were strongly associated with favorable breast appearance (Table 3). Conversely, rupture (OR =3.06, 95% CI: 1.15–8.11, P=0.03) and lesions located in the lower inner quadrant (OR =10.22, 95% CI: 2.06–50.76, P=0.004) were identified as risk factors (Table 3). Multivariate logistic regression confirmed that LBDR (OR =0.00, 95% CI: 0.00–0.03, P=0.001) was an independent protective factor for favorable postoperative breast appearance in PCM patients (Table 3).

We also evaluated the effectiveness of LBDR in preventing postoperative recurrence (Table 2). Compared to the traditional surgery group, LBDR significantly reduced the recurrence rate (4.55% vs. 54.17%, P<0.001). Univariable logistic regression analysis identified LBDR (OR =0.06, 95% CI: 0.01–0.23, P<0.001) and higher BMI (OR =0.81, 95% CI: 0.66–1.00, P=0.045) as protective factors against postoperative recurrence of PCM (Table 4). Multivariate logistic regression analysis confirmed that LBDR (OR =0.06, 95% CI: 0.01–0.25, P<0.001) was an independent protective factor against postoperative recurrence (Table 4).

Finally, we compared the surgical outcomes between the two groups. There were no significant differences in perioperative bleeding nor complications between the LBDR and traditional surgery groups (Table 5). LBDR was associated with a longer operating time compared to traditional surgery (median: 90 vs. 82.5 min, P=0.02).

Discussion

Surgical treatment for PCM presents unique challenges because of the complexity of the disease (7,13). Achieving complete lesion removal while preserving breast symmetry and aesthetic appearance is often difficult (13). Extensive lesion excision leaves limited residual tissue, complicating breast reconstruction. This study, based on an analysis of 90 cases, demonstrated that LBDR effectively addresses these issues, minimizing breast deformity and reducing psychological distress.

In the early stages of PCM, ductal dilation around the nipple underpins disease progression (14). Ultrasonography often reveals 2–4 dilated ducts radiating from the nipple. Surgical incisions along the nipple-areolar complex are ideal for accessing these areas. For mixed-type PCM, where large lesions with multiple ulcerated foci occur, extended areolar incisions to the upper outer quadrant allowed for effective excision. These inconspicuous incisions significantly improved aesthetic outcomes and are well-received by patients.

For cases with insufficient residual tissue post-excision, layered tissue flap rotation played a pivotal role in breast reconstruction. The breast comprises layers of skin, subcutaneous tissue, fat, glandular tissue, and fascia. Tissue flaps primarily derived from the fat and glandular layers proved superior to skin-included flaps, which tend to result in longer incisions, prominent scars, and suboptimal aesthetic outcomes. For larger defects, flaps from adjacent areas were rotated to fill residual cavities, with flap thickness preoperatively estimated based on defect size. The versatility of this technique allowed for effective management of defects in various directions, ensuring superior contour preservation. Most cases achieved satisfactory results with high patient satisfaction.

Defects following excision pose distinct challenges, particularly beneath the nipple, where insufficient residual tissue can lead to nipple retraction and compromised aesthetics (15). Since nipple retraction can directly affect the patency of the mammary ducts, leading to ductal dilation and thus recurrence, correcting nipple retraction is also paramount to prevent recurrence (16,17). Layered tissue flap rotation has emerged as a critical technique in reconstruction. Tissue flaps derived from fat and glandular layers were superior to skin-included flaps, which resulted in longer incisions, prominent scars, and suboptimal cosmetic outcomes. For larger defects, adjacent flaps were rotated to fill cavities, with flap thickness preoperatively estimated based on defect size. This versatile technique allowed for effective defect management in various directions, ensuring superior contour preservation and high patient satisfaction.

Reconstruction of the subareolar area requires overlapping glandular and fat flaps to stabilize the nipple (3). For older patients with reduced tissue elasticity, glandular flaps are preferred, while younger patients often require multiple flaps from different quadrants to provide optimal support and achieve natural contouring. Importantly, areas reconstructed with fat flaps exhibit progressive fullness over time, suggesting potential adipose tissue regeneration, which warrants further investigation into the role of adipose stem cells.

Skin preservation also plays a pivotal role in maintaining breast appearance. Minimal skin excision, even in cases with extensive lesions or multiple fistulas, preserves overall breast shape. Traditional surgery methods, by contrast, often lead to severe deformities, with loss of breast contours, marked asymmetry, significant nipple displacement, and poor cosmetic outcomes. For mixed-type PCM requiring skin excision, ulcerated or impending ulcerated skin is removed, while intact skin is preserved. Preoperative localization and thorough assessment following skin excision are critical to reducing residual lesions and recurrence.

There are several limitations in this study. First, its retrospective design may have introduced selection bias, despite the application of strict inclusion and exclusion criteria to mitigate this. Second, the small sample size necessitates further, large, multicenter studies to validate the findings. Additionally, long-term follow-up data are required to fully assess the durability of surgical outcomes and recurrence rates.

Finally, while this study focused on clinical and aesthetic outcomes, it also highlighted the potential for broader clinical adoption of LBDR. LBDR incorporates simplified oncoplastic concepts that do not require advanced microsurgical or plastic surgery training. In our experience, the learning curve for LBDR is relatively short, and surgeons with general breast surgery experience can master the technique after standardized training and practice. This makes LBDR an accessible option even in non-tertiary or resource-limited settings. Moreover, LBDR relies solely on autologous tissue advancement without the need for prosthetic materials or specialized equipment, which may reduce overall surgical costs compared to more complex reconstructive techniques. Taken together, the feasibility, reproducibility, and cost-effectiveness of LBDR suggest it has strong potential for widespread implementation in the surgical management of PCM.

Conclusions

Our findings suggest that LBDR may provide improved cosmetic outcomes and potentially reduce recurrence rates compared to traditional surgery in patients with PCM. These preliminary results highlight the promise of LBDR, especially for patients with extensive lesions or high aesthetic demands. However, given the retrospective design and lack of randomized controlled trials, further prospective, multicenter studies are warranted to confirm the efficacy and safety of LBDR.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-99/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-99/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-99/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-99/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Third Medical Center of Chinese PLA General Hospital (No. KY2002-020) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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