Implant volume estimation in direct-to-implant breast reconstruction after nipple-sparing mastectomy

The wide base bipedicled (WIBB) flap in nipple-sparing skin-reducing mastectomy

In this article, we present a modification of the NS/SRM technique in which the mastopexy design for skin reduction is undertaken with a wide-base bipedicled (WIBB) flap. The WIBB flap can be applied in both autologous and implant-based breast reconstruction. Our reconstructive algorithm is also presented. The clinical data of patients operated on from June 2017 to November 2022 were collected: 51 patients for a total of 71 breasts. Personal data, BMI, type and volume of implants used, and major and minor complications were analyzed by descriptive statistics. The mean age was 48.3 years. BMI ranged between 21.5 and 30.9 kg/m2. Thirty-one patients underwent unilateral mastectomy, while twenty patients underwent bilateral surgery. In 25 breasts, immediate reconstruction was performed with implants and ADM. In 40 breasts, reconstruction was performed with a subpectoral tissue expander, and in 6 breasts, reconstruction was performed with a DIEP flap. We observed only one case (1.4%) of periprosthetic infection requiring implant removal under general anesthesia. Minor complications occurred in 14.1% of patients. The use of both the WIBB flap and our algorithm maintained a low complication rate in our series, ensuring oncological radicality and a good aesthetic result at the same time.

Analyzing mastectomy and reconstruction weight in immediate autologous breast reconstruction: A preliminary study

BACKGROUND

This study aims to explore the ideal breast size by assessing the relationship between mastectomy to free flap weight ratio and complications as well as patient-reported outcomes in autologous breast reconstruction (ABR).

METHOD

A retrospective review of patients undergoing bilateral immediate ABR with mastectomy and flap weights available was completed. Patients were divided into three groups based on the ratio of mastectomy to flap weights. The patients were grouped as "maintained" if the flap weight was within 10% of the mastectomy weight. Patients with a weight difference greater than 10% were used to declare "downsized" or "upsized." Outcomes included complications and four domains of the BREAST-Q at 1-year postoperatively.

RESULTS

Three hundred and fifty-nine patients were included in the analysis, of which 112 were downsized, 91 maintained, and 156 upsized, respectively. Presence of complications did not significantly differ among the groups. At 1-year postoperatively, Sexual Well-being significantly differed (p = 0.033). Between preoperative and 1 year, patients who upsized experienced an improvement in Satisfaction with Breasts by 16 points (p < 0.001), while patients who downsized experienced a decline in Physical Well-being of the Chest by 7 points (p = 0.016). Multivariable linear regression model showed that Sexual Well-being was 13 points lower in the downsized cohort than in the maintained cohort (β = -13, 95% confidence interval: -21 to -5.4; p = 0.001).

CONCLUSION

Although complication rates do not significantly differ between the three cohorts, patients who downsize may have lower Sexual Well-being postoperatively. Surgeons should consider our preliminary findings to counsel patients preoperatively about the predicted breast size and the impact of downsizing on sexual health.

Patient Self-reported Breast Cup Size and Resultant Mastectomy Specimen Weight: Implications for Reconstructive Breast Surgery

Breast cup sizing irregularities exist due to discrepancy between garment manufacturers and patient reported measurements making it difficult to assess true preoperative and definitive postoperative breast cup size. This study aims to evaluate the association between patient self-reported breast cup size and mastectomy specimen weight as a way to determine postreconstruction breast cup size.

METHODS

This is a retrospective study that evaluated patients who underwent bilateral mastectomy at an academic center between 2019-2021. Cup size and mastectomy weight were our only independent and dependent variables, respectively. Covariates that were assessed included chest circumference, surgical oncologist, BMI, race, and age.

RESULTS

243 patients were evaluated as a part of this study who underwent either total-simple (TS; 29), skin-sparing (SS; 146), or nipple-sparing (NS; 68) bilateral mastectomy. There were positively weak correlations using nonparametric correlation analysis for breast cup size to mastectomy weight in patients who underwent TS (r = 0.375; p = 0.004), SS (r = 0.353; p <0.001), and NS (r = 0.246; p = 0.004) mastectomy. The multivariate linear regression for TS (R₂=0.520; p < 0.001), SS (R₂=0.573; p < 0.001) and NS (R2=0.396; p < 0.001) mastectomy were significant. Covariates assessed in the regression showed BMI significant for all types, age for TS type, and SS type for breast surgeon and chest circumference.

CONCLUSIONS

There is a positively weak correlation between preoperative breast cup size and mastectomy weight, providing evidence for the difficulty of estimating postoperative breast cup size. Thus, the conversation with the patient should focus on breast appearance and quality of life rather than postreconstruction breast size.

Prediction of Implant Size Based on Breast Volume Using Mammography with Fully Automated Measurements and Breast MRI

BACKGROUND

Determination of implant size is crucial for patients with breast cancer undergoing one-stage breast reconstruction. The purpose of this study is to predict the implant size based on the breast volume measured by mammography (MG) with a fully automated method, and by breast magnetic resonance imaging (MRI) with a semi-automated method, in breast cancer patients with direct-to-implant reconstruction.

PATIENTS AND METHODS

This retrospective study included 84 patients with breast cancer who underwent direct-to-implant reconstruction after nipple-sparing or skin-sparing mastectomy and preoperative MG and MRI between April 2015 and April 2019. Breast volume was measured using (a) MG with a fully automated commercial software and (b) MRI with an in-house semi-automated software program. Multivariable regression analyses including breast volume and patient weight (P < 0.05 in univariable analysis) were conducted to predict implant size.

RESULTS

MG and MRI breast volume was highly correlated with both implant size (correlation coefficient 0.862 and 0.867, respectively; P values < 0.001) and specimen weight (correlation coefficient 0.802 and 0.852, respectively; P values < 0.001). Mean absolute difference between the MR breast volume and implant size was 160 cc, which was significantly higher than that between the MG breast volume and implant size of 118 cc (P < 0.001). On multivariable analyses, only breast volume measured by both MG and MRI was significantly associated with implant size in any implant type (all P values < 0.001).

CONCLUSION

Breast volume measured by MG and MRI can be used to predict appropriate implant size in breast cancer patients undergoing direct-to-implant reconstruction in an efficient and objective manner.

Prediction of the Ideal Implant Size Using 3-Dimensional Healthy Breast Volume in Unilateral Direct-to-Implant Breast Reconstruction

Background and objectives: There is no consensus regarding accurate methods for assessing the size of the implant required for achieving symmetry in direct-to-implant (DTI) breast reconstruction. The purpose of this study was to determine whether the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight, and to compare prediction performances between the two variables. Materials and Methods: Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this study. Breast volumes were measured using 3D surface imaging preoperatively and at postoperative three months. Ideal implant size was calculated by correcting the used implant volume by the observed postoperative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models. Results: A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 vs 0.759, p < 0.001). Conclusions: The 3D volume of the healthy breast is a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. The estimation formula obtained in this study may assist in the selection of the ideal implant size in unilateral DTI breast reconstruction.