Skin-Sparing Mastectomy and Immediate Tissue Expander Breast Reconstruction in Patients With Macromastia Using the Passot Breast Reduction Pattern

Passot-Type Immediate Breast Reconstruction Obviates the Use of Aceullular Dermal Matrix in Grades 2 and 3 Ptosis

PURPOSE

Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM.

METHODS

All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided.

RESULTS

Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case).

CONCLUSIONS

Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.

Dermal Autograft Using Donor Breast as Alternative to Acellular Dermal Matrices in Tissue Expander Breast Reconstruction: A Comparative Review

BACKGROUND

Shifting preference for implant-based breast reconstruction has resulted in an increased use of acellular dermal matrix (ADM) in tissue-expander breast reconstruction. The benefits afforded by ADM must be weighed against a potential increased risk for postoperative complications. Dermal autograft-assisted breast reconstruction using autograft harvest from the lower abdomen has been shown to result in equivalent aesthetics and patient satisfaction compared with ADM at a lower cost, with fewer complications. The purpose of this study was to review a series of patients who underwent bilateral mastectomy and immediate dermal autograft-assisted tissue expander (TE) breast reconstruction using the non-cancerous breast as a donor site, comparing the outcomes with a concurrent cohort of patients undergoing ADM-assisted reconstruction to determine the relative safety, cost, and effectiveness of the 2 procedures.

METHODS

The study population included all patients who underwent dermal autograft-assisted TE breast reconstruction, using the contralateral cancer-free breast as the source of dermal autograft, between 2010 and 2015. The ADM cohort consisted of patients who underwent bilateral mastectomy and immediate ADM-assisted TE breast reconstruction during the same period. Univariate analysis was performed for demographic data, complications, operative cost, and operative time. Data were compared using the Wilcoxon rank sum test for nonparametric data and χ analyses for continuous and categorical variables. Significance was defined as P value less than 0.05.

RESULTS

Seventeen patients received dermal autograft using the non-cancerous breast donor site. Twenty-seven patients who underwent ADM-assisted reconstruction during the same period were identified. Significantly higher cost was demonstrated between groups (ADM, US $9999.87; autograft, US $3924.19; P < 0.0001). No significance difference existed operative time (autograft, 97 min; ADM, 120 min). No difference was found in wound healing complications (ADM, 14.8%; autograft, 23.53%; P = 0.47). No significant difference was found in major complications (ADM, 26%; autograft, 17.65%; P = 0.52) or infectious complications (ADM, 26%; autograft, 17.65%; P = 0.52).

CONCLUSIONS

Dermal autograft-assisted breast reconstruction using the contralateral non-cancerous breast as the source of dermal autograft harvest represents a lower cost alternative to ADM without increased risk of postoperative complications.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures

BACKGROUND

In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate.

OBJECTIVES

We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF.

METHODS

Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed.

RESULTS

Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001).

CONCLUSIONS

The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts.

LEVEL OF EVIDENCE 4

Mastectomy skin flap necrosis: challenges and solutions

Introduction

Mastectomy skin flap necrosis (MSFN) has a reported incidence of 5%–30% in the literature. It is often a significant and underappreciated problem. The aim of this article was to review the associated challenges and possible solutions.

Methods

A MEDLINE search was performed using the search term “mastectomy skin flap necrosis”. Titles and abstracts from peer-reviewed publications were screened for relevance.

Results

MSFN is a common complication and may present as partial- or full-thickness necrosis. Predictive patient risk factors include smoking, diabetes, obesity, radiotherapy, previous scars and severe medical comorbidity. MSFN leads to a number of challenges, including wound management problems, delays to adjuvant therapy, esthetic compromise, implant extrusion, patient distress and financial loss. Careful preoperative planning and meticulous surgical technique may reduce the incidence of MSFN. A number of intraoperative techniques are available to try and predict skin flaps at risk of MSFN. MSFN may be managed operatively or nonoperatively. Early intervention may reduce the morbidity of MSFN in selected cases. Topical nitroglycerin ointment may be beneficial in reducing MSFN following immediate reconstruction, but the evidence base is still limited.

Conclusion

MSFN can result in considerable challenges for the patient and the health care service. This review discusses the management options for this problem.

Prosthetic Breast Reconstruction With Acellular Dermal Matrices: Achieving Predictability and Reproducibility

The use of acellular dermal matrices in the setting of prosthetic breast reconstruction has captured the attention of many plastic surgeons. The regenerative capacity of these materials has provided additional tissue support to the mastectomy skin flaps with the ultimate result of improving surgical and aesthetic outcomes. Despite the benefits, there remains a significant diversity with regard to outcomes with some surgeons reporting increased morbidity. The reasons for this are varied but ultimately related to differences in patient selection and surgical techniques. The purpose of this article is to provide strategies for using acellular dermal matrix to achieve success in a manner that is usually associated with outcomes that are predictable and reproducible.

Risk Factors for Complications in Immediate Expander-Implant Breast Reconstruction for Non-obese Patients: Impact of Breast Size on Complications

BACKGROUND

Although obesity is a well-known risk factor for complications in immediate expander-implant breast reconstruction, no studies have identified risk factors for non-obese patients. The purpose of this study was to identify risk factors for complications in non-obese patients.

METHODS

A retrospective analysis of prospectively collected data from 397 consecutive immediate expander-implant breast reconstructions in 367 non-obese patients at a single institution over a 5-year period was conducted. Univariable and multivariable analysis were performed to determine the influence of six patient-related and eight procedure-related characteristics on complications.

RESULTS

Mean BMI was 21.7 ± 2 kg/m(2) and median mastectomy weight was 298.0 g (range: 40-1164 g). Multivariable analysis showed that neither BMI nor the use of acellular dermal matrix was a predictor for complications. Adjuvant radiation (odds = 3.12, p < 0.001) and mastectomy weight (p < 0.001) were independent risk factors for complications. A 100 g increase in the mastectomy weight was significantly associated with a 23 % increase in the odds of overall complications (p = 0.003), major complications (p = 0.004), and skin flap complications (p = 0.007), as well as a 28 % increase in the odds of seroma (p = 0.044), but was not associated with reconstruction failure. Adjuvant radiation (p < 0.001) and hypertension (p < 0.001) were risk factors for reconstruction failure.

CONCLUSIONS

Breast size was an independent risk factor for complications in non-obese patients while BMI was not. In the reconstruction of large breasts, greater attention and additional adjunctive procedures would be needed to prevent complications.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Patient-Report Satisfaction and Health-Related Quality of Life in TiLOOP® Bra-Assisted or Implant-Based Breast Reconstruction Alone

INTRODUCTION

Implant-based breast reconstructions (IBBR) using alternatives to acellular dermal matrixes are increasing. Data on complications are limited, and information concerning health-related quality of life (HR-QoL) following the use of these synthetic meshes do not exist.

METHODS

Between January 2006 and January 2013, patients undergoing immediate or delayed-immediate IBBR with or without titanium covered polypropylene mesh (TiLOOP® Bra) were investigated. HR-QoL was assessed using the validated self-reporting BREAST-Q questionnaire. Patient demographics and complications were evaluated retrospectively. Stepwise regression backward elimination analysis was performed to identify influential factors on each BREAST-Q domain.

RESULTS

Of the 90 women, 42 had IBBR alone and 48 in combination with TiLOOP® Bra. The mean follow-up was 18 months in the TiLOOP® Bra and 17.5 months in the implant alone group (p = 0.827). The overall complication rate was 21.1 %, with 14.6 % in the TiLOOP® Bra and in 28.6 % in the implant alone group (p = 0.105). Capsular contraction rate was 4.4 % in the TiLOOP® Bra and 16.7 % in the implant alone group (p = 0.052). The analysis of the HR-QoL showed no significant differences between the groups. Surgeries prior to IBBR had a positive influence on HR-QoL. TiLOOP® Bra was associated with a negative effect on "satisfaction with breast" (β = -5.72; p < 0.001), as it was no longer observed for "satisfaction with outcome" and other domains.

Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study

BACKGROUND

Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors.

METHODS

A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis.

RESULTS

Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity.

CONCLUSIONS

Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.