Putting Together the Pieces: Development and Validation of a Risk-Assessment Model for Nipple-Sparing Mastectomy

Modern Approaches to Implant-Based Breast Reconstruction

The modern approach to implant-based breast reconstruction encompasses an evolution in surgical techniques, patient selection, implant technology, and use of support materials. Successful outcomes are defined by teamwork throughout the ablative and reconstructive processes as well as appropriate and evidence-based utilization of modern material technologies. Patient education, focus on patient-reported outcomes, and informed and shared decision-making are the key to all steps of these procedures.

Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy

BACKGROUND

Preoperative vascular mapping has been demonstrated to be an excellent adjunct to perforator flap surgery by reducing operative times and enhancing surgical precision. This study evaluated the benefit of preoperative vascular mapping using magnetic resonance imaging and Doppler ultrasonography to identify the different perforators to the breast and compared it to postoperative mapping. The authors' intent was to determine whether preoperative knowledge of the various vascular sources to the nipple-areola complex affected the outcome and vitality of the nipple-areola complex.

METHODS

A prospective study was performed on 15 patients undergoing 25 nipple-sparing mastectomies for breast cancer or genetic predisposition. Ten patients underwent bilateral mastectomy, and five underwent unilateral mastectomy. Mean age was 52 years (range, 30 to 76 years). The mean patient body mass index was 22.4 kg/m2 (range, 20 to 35 kg/m2). Inclusion criteria consisted of breast cancer or genetic predisposition and grade 1 or 2 breast ptosis. Exclusion criteria included prior breast surgery, grade 3 ptosis, and gigantomastia. All patients underwent immediate direct-to-implant reconstruction.

RESULTS

Preoperative vascular mapping by magnetic resonance imaging and external Doppler ultrasonography was performed in all 15 patients. In all 25 breasts, the fifth anterior intercostal artery perforator was identified preoperatively and preserved intraoperatively. Postoperative imaging demonstrated patency of the fifth anterior intercostal artery perforator vessels in all patients. Nipple-areola viability was demonstrated in all breasts.

CONCLUSIONS

This study demonstrates that preoperative magnetic resonance imaging and Doppler ultrasonography for mapping breast perforator vessels is a useful strategy and should be considered for select patients undergoing nipple-sparing mastectomy. Identification of dominant perforators to the breast allowed mastectomy planning with preservation of the important perforator to the mastectomy skin flaps and nipple-areola complex.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Individualized Risk Prediction Tool for Serious Wound Complications After Mastectomy With and Without Immediate Reconstruction

BACKGROUND

A greater proportion of patients with surgical risk factors are undergoing immediate breast reconstruction after mastectomy, resulting in the need for better risk prediction to inform decisions about the procedure. The objective of this study was to leverage clinical data to restructure a previously developed risk model to predict serious infectious and noninfectious wound complications after mastectomy alone and mastectomy plus immediate reconstruction for use during a surgical consultation.

METHODS

The study established a cohort of women age 21 years or older treated with mastectomy from 1 July 2010 to 31 December 2015 using electronic health records from two hospitals. Serious infectious and non-infectious wound complications, defined as surgical-site infection, dehiscence, tissue necrosis, fat necrosis requiring hospitalization, or surgical treatment, were identified within 180 days after surgery. Risk factors for serious wound complications were determined using modified Poisson regression, with discrimination and calibration measures. Bootstrap validation was performed to correct for overfitting.

RESULTS

Among 2159 mastectomy procedures, 1410 (65.3%) included immediate implant or flap reconstruction. Serious wound complications were identified after 237 (16.8%) mastectomy-plus-reconstruction and 30 (4.0%) mastectomy-only procedures. Independent risk factors for serious wound complications included immediate reconstruction, bilateral mastectomy, higher body mass index, depression, and smoking. The optimism-corrected C statistic of the risk prediction model was 0.735.

CONCLUSIONS

Immediate reconstruction, bilateral mastectomy, obesity, depression, and smoking were significant risk factors for serious wound complications in this population of women undergoing mastectomy. Our risk prediction model can be used to counsel women before surgery concerning their individual risk of serious wound complications after mastectomy.

An Ounce of Prediction is Worth a Pound of Cure: Risk Calculators in Breast Reconstruction

Preoperative risk calculators provide individualized risk assessment and stratification for surgical patients. Recently, several general surgery–derived models have been applied to the plastic surgery patient population, and several plastic surgery–specific calculators have been developed. In this scoping review, the authors aimed to identify and critically appraise risk calculators implemented in postmastectomy breast reconstruction.

A Novel Artificial Intelligence-assisted Risk Assessment Model for Preventing Complications in Esthetic Surgery

Prevention of complications to reduce morbidity and mortality, and improve patient satisfaction is of paramount importance to plastic surgeons. This study aimed to evaluate the predictive risk factors for complications and to validate a novel risk assessment model, using artificial intelligence.

METHODS

A retrospective review of esthetic surgery procedures performed by the author between 2015 and 2020 was conducted. The Pearson correlation test was used to analyze the risk factors and complications. Differences in the mean risk scores among the three risk groups were tested using one-way analysis of variance. Risk scoring was validated using a machine learning process with a support vector machine in a Google Colaboratory environment.

RESULTS

Of the 372 patients, 28 (7.5%) experienced complications. The Pearson correlation coefficients between the risk score and body mass index (BMI: 0.99), age (0.97), and Caprini score of 5 or more (0.98) were statistically significant (P < 0.01). The correlations between the risk scores and sex (-0.16, P = 0.58), smoking habit (-0.16, P = 0.58), or combined procedures (-0.16, P = 0.58) were not significant. Necrosis was significantly correlated with dehiscence (0.92, P = 0.003) and seroma (0.77, P = 0.041). The accuracy of the predictive model was 100% for the training sample and 97.3% for the test sample.

CONCLUSIONS

Body mass index, age, and the Caprini score were risk factors for complications following esthetic surgery. The proposed risk assessment system is a valid tool for improving eligibility and preventing complications.

Ischemic Complications After Bilateral Nipple-sparing Mastectomy and Implant-based Reconstruction: A Critical Analysis

PURPOSE

Nipple-sparing mastectomy (NSM) has a higher incidence of mastectomy skin flap necrosis (MSFN) than skin-sparing mastectomy. The purpose of this study is to analyze predisposing factors for nipple and skin necrosis after bilateral NSM with immediate implant reconstruction.

METHODS

Sixty-two consecutive patients (124 breasts) from a single breast/plastic surgeon underwent bilateral NSM with immediate implant-based breast reconstruction were included. Factors influencing MSFN were analyzed.

RESULTS

The mean age was 45.7 years, and mean body mass index was 22.9. Reconstructive methods were as follows: tissue expander (TE), 76 (61.3%); and direct to implant, 48 (38.7%). Mastectomy skin flap necrosis occurred in 39 (31.5%) breasts, nipple necrosis 38 and skin flap necrosis 19. Thirty-seven breasts healed uneventfully, and 2 (1.6%) required reoperation. Cancer pathology, mastectomy weight greater than 279 g, TE reconstruction, and nipple-notch (N-N) distance greater than 23 cm were predictive of nipple necrosis on univariate analysis. The mean mastectomy weight (380.1 g vs 220.7 g, P < 0.0001), N-N distance greater than 23 cm (30 vs 0, P < 0.0001), and mean implant size (490 cm3 vs 373 cm3, P < 0.0001) were greater in the TE group. On logistic regression model controlling for all significant variables, predictors of MSFN were as follows: diagnosis of cancer (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.41-8.03; P = 0.006), TE reconstruction (OR, 2.87; 95% CI, 1.03-8.03; P = 0.04), and N-N distance (OR, 1.31; 95% CI, 1.03-1.66; P = 0.03).

CONCLUSIONS

Mastectomy skin flap necrosis after NSM and implant reconstruction is common. In this series, only 2 (1.6%) cases required surgical intervention with no implant loss. Treatment of breast cancer, TE reconstruction, and increasing N-N notch distance were positive predictors of MSFN.

Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.