Dual-Plane Prosthetic Reconstruction Using the Modified Wise Pattern Mastectomy and Fasciocutaneous Flap in Women with Macromastia:

Autoderm in Direct-to-implant Prepectoral Breast Reconstruction Decreases Perioperative Complication Rates and Improves Reconstructive Outcomes

Background

Wise pattern skin incision in breast reconstruction following mastectomy facilitates removal of skin excess in patients with large and ptotic breasts. The trifurcation of the inverted-T incision poses increased risk of infection and reconstructive failure in implant reconstruction. Autoderm has been described in subpectoral implant-based reconstruction. In this case series, it is described in prepectoral implant-based reconstruction.

Methods

A retrospective review of breast cancer patients who underwent either unilateral or bilateral skin-reducing mastectomy via immediate prepectoral implant-based breast reconstruction in conjunction with an inferiorly based autoderm flap for implant coverage between February 2022 to April 2024 was performed and compared with previously published Wise pattern outcomes.

Results

Ten patients (15 breasts) underwent immediate prepectoral implant-based breast reconstruction with an inferiorly-based autoderm flap. Implant sizes ranged from 300 to 800 mL. Autoderm was able to cover the implant under the inverted-T incision in 13 breasts, whereas 1 breast required extension of the dermal flap using acellular dermal matrix. No major complications were observed in this study. One patient developed delayed wound healing in 1 breast that was managed nonoperatively. The test of 2 proportions was used to compare complications to published rates. Rate of delay wound healing showed no significant difference (P = 0.38), whereas the overall complication rate was lower (P < 0.05).

Conclusions

The inferiorly based autoderm flap in immediate prepectoral implant-based breast reconstruction is a safe and effective option in managing patients with large and ptotic breasts that reduces the rate of infection and reconstructive failure.

Wise Versus Vertical Mastopexy Pattern Skin-reducing Mastectomy With Immediate Breast Reconstruction: Systematic Review and Meta-analysis

Background

This study compares postoperative outcomes of Wise and vertical mastopexy pattern skin-reducing/skin-sparing masctomy, hypothesizing that incision choice affects cosmetic outcomes and complication rates.

Methods

A systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching PubMed, MEDLINE, Embase, Web of Science, and StarPlus Library. Included studies documented skin-sparing mastectomy using Wise or vertical mastopexy patterns with immediate reconstruction. The primary outcome is total mastectomy flap necrosis. The secondary outcomes are major/minor necrosis, infection, hematoma, seroma, and wound complications. Bayesian and frequentist generalized linear mixed models were used for the meta-analysis, including studies with 0 events.

Results

Sixty-six studies were identified, with 39 included in the meta-analysis, comprising 1954 patients and 2311 breast reconstruction cases. The Wise group had a higher rate of mastectomy flap necrosis (14.2%; 95% confidence interval: 10%-20%; I² = 83%) compared with the vertical group (7.8%; 95% confidence interval: 5%-12%; I² = 0%) (P < 0.05). No significant differences were found in other domains. Subgroup analysis favored vertical mastopexy for wound-related complications (P = 0.04).

Conclusions

The Wise pattern shows significantly higher mastectomy flap necrosis than the vertical pattern. However, there were no significant differences in major necrosis, minor necrosis, infection, hematoma, or seroma. Future studies should focus on larger, high-quality randomized controlled trials to better understand the impact of incision techniques on postoperative outcomes.

BRM: From Skin-Reducing Mastectomy to the New Concept of Breast Reshaping Mastectomy

Background: Macromastia is a well-known issue in breast reconstruction. Skin-reducing mastectomy (SRM) was introduced as a skin-sparing mastectomy that utilizes a skin reduction pattern similar to breast reduction or breast lift surgery, specifically to manage hypertrophic and pendulous breasts. Over time, numerous authors have contributed to refining the SRM technique, leading to the development of various technical variants. However, the diversity of approaches inspired by SRM has created confusion, and clear surgical indications are lacking. Methods: We propose a unifying concept called breast reshaping mastectomy (BRM), which encompasses all techniques based on SRM principles. The BRM aims not only to preserve and reduce the breast skin envelope but also to immediately reshape it for a more aesthetic outcome. This approach is applicable to all mastectomies where skin envelope preservation (with or without the nipple-areola complex) is oncologically safe, a modification of breast skin coverage is needed for better aesthetic results, and an implant-based reconstruction is planned. Results: To define the BRM concept, we reviewed the existing literature on SRM and its related techniques. Our analysis focused on four key elements: skin incision pattern, implant coverage strategy, nipple-areola complex (NAC) management, and the choice between two-stage and direct-to-implant reconstruction. Conclusions: By integrating these four components into a single surgical framework, BRM provides a structured approach to breast reconstruction that enhances both oncologic safety and aesthetic outcomes. Standardizing these techniques could help clarify surgical indications and improve reconstructive planning for patients undergoing skin-sparing mastectomy.

Breast Implant Reconstruction in the Ptotic Patient: Evaluation of Wise and Vertical Skin Sparing Mastectomy

Introduction: Post-mastectomy reconstruction in patients with severe breast ptosis can be challenging. Traditionally, a skin sparing mastectomy (SSM) with a circumareolar incision or a horizontal elliptical extension results in a long, horizontally-oriented scar in the central breast. The Wise pattern SSM with an inferiorly-based dermal flap addresses skin redundancy and provides added vascularized implant coverage in ptotic patients with macromastia. The purpose of this study is to compare outcomes in ptotic patients undergoing SSM with Wise pattern and a modified vertical technique which also uses de-epithelialized excess skin under the incision. Methods: A retrospective chart review was performed on patients that underwent SSM using a Wise or vertical skin reducing technique. The Wise pattern was performed using an inferiorly-based dermal flap and the vertical method used a laterally-based dermal flap covering the implant/tissue expander (TE). Results: SSM with the use of autoderm was performed in 42 patients (67 breasts) using either the Wise (n = 49 breasts) or vertical (n = 18 breasts) method. Both groups had similar BMI (35.4). The prepectoral plane was used in 93.5% of Wise pattern patients and all vertical patients. All cases of seroma and hematoma occurred in the Wise pattern group (10.2%). Mastectomy skin necrosis requiring unplanned return to surgery for debridement occurred in 20.4% of those undergoing Wise pattern SSM and 11.1% undergoing the vertical pattern (p = 0.49). Conclusion: Severely ptotic patients undergoing SSM have a high risk of skin necrosis. A dermal flap under the closure has the advantage of vascularized tissue reinforcing the wound in implant based reconstruction. The vertical pattern SSM using a laterally-based dermal flap may be a safe, simple alternative to the Wise pattern in select patients.

Wise-Pattern Mastectomy with an Inferior Dermal Sling: A Viable Alternative to Elliptical Mastectomy in Prosthetic-Based Breast Reconstruction

BACKGROUND

Prosthetic-based postmastectomy breast reconstruction in patients with large or pendulous breasts remains challenging because of inelastic and redundant skin, with various approaches to skin reduction at the time of mastectomy. This study describes the authors' experience with a Wise-pattern inferior dermal sling approach to skin-sparing mastectomy.

METHODS

Retrospective chart review was performed on patients who underwent immediate prosthetic-based breast reconstruction after mastectomy from 2009 to 2021. A total of 240 patients who underwent Wise-pattern skin-sparing mastectomy (WSSM) were compared with a cohort of patients who had traditional elliptical skin-sparing mastectomy (ESSM), matched for mastectomy weight, prior radiation therapy, and smoking. Ninety-day postsurgical outcomes were examined.

RESULTS

The WSSM cohort had a significantly higher body mass index (30.3 kg/m 2 versus 26.9 kg/m 2 ; P < 0.0001) and mastectomy weight (831 g versus 607 g; P < 0.0001). After propensity score matching, there was no significant difference in complication or treatment rates between WSSM and ESSM breasts except for mastectomy flap necrosis (11.6% versus 5.0%; P = 0.0082). WSSM patients who had mastectomy flap necrosis did not have significantly different treatment rates of admission, return to the operating room, or explantation compared with ESSM patients.

CONCLUSIONS

In the largest reported series to date, WSSM was associated with a higher rate of mastectomy flap necrosis, but this did not translate into statistically significant differences in treatment. The inferior dermal flap likely acts as a protective layer of vascularized tissue, which appears to prevent evolution of mastectomy skin flap necrosis into more serious adverse outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Safety of Augmenting Breast Volume in Direct-to-Implant Breast Reconstruction With Contralateral Breast Augmentation: Comparison With 2-Stage Reconstruction

BACKGROUND

Direct-to-implant breast reconstruction is a standard method of implant-based reconstruction; however, the risk of skin necrosis and implant failure exists. During simultaneous contralateral augmentation, an implant larger than the resected tissue must be inserted to balance both sides, which may increase the risk of complications. This study examined the differences in the incidence of complications between the single-stage direct-to-implant reconstruction and 2-stage reconstruction when contralateral augmentation was performed simultaneously.

METHODS

This study included 99 patients who underwent implant-based breast reconstruction with contralateral augmentation between 2012 and 2020. A retrospective chart review was conducted and the patients were divided into 2 groups: the single-stage reconstruction (n = 61) and 2-stage reconstruction (TSR, n = 38) groups. Demographic data and surgical and oncological information were collected. Complications including skin necrosis and reconstruction failure were investigated as the primary outcome.

RESULTS

Implant volume and contralateral implant volume were significantly greater in TSR group than in the single-stage reconstruction group. There were no significant differences in the incidence of complications and reconstruction failure rates between both groups. The nipple-sparing mastectomy was the risk factor for complications. Furthermore, the risk factors for mastectomy skin necrosis were implant volume and differences in the volume of both implants.

CONCLUSIONS

Single-stage reconstruction did not increase the risk of complications compared with TSR when implants that were larger than the resected tissue were inserted after mastectomy. Proper patient selection and selection of implants that are not excessively large could satisfy patients' cosmetic needs in a single operation.

Wise Pattern versus Transverse Pattern Mastectomy in Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

The Wise pattern adapted to mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. The authors compared the time for exchange, time to initiate postmastectomy radiotherapy, and complication rates between Wise pattern and transverse incision pattern reconstructions.

METHODS

Records of patients who underwent immediate, two-stage, implant-based breast reconstruction (IBBR) between January of 2011 and December of 2020 were retrospectively reviewed. Two cohorts were compared according to the incision pattern: Wise pattern versus transverse incision pattern. Complications were compared after propensity score matching.

RESULTS

The authors initially analyzed 393 two-stage immediate IBBRs in 239 patients [91 IBBRs (23.2%) in the Wise pattern group and 302 (76.8%) in the transverse pattern group]. Expansion time (53 days versus 50 days, P = 0.9), time for tissue expander-to-implant exchange (154 versus 175 days, P = 0.547), and time to initiate postmastectomy radiotherapy (144 days versus 126 days, P = 0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, P < 0.001) and the 30-day rate of wound complications requiring excision/débridement and closure procedures (20% versus 7%, P < 0.001) were significantly higher in the Wise pattern group. After propensity score matching, the 30-day rate of wound complications was persistently higher (25% versus 10%, P = 0.03) in the Wise pattern group.

CONCLUSIONS

The Wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed tissue expander placement may improve the safety profile of this procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Language of Implant-based Breast Reconstruction: Can We Do Better?

The management of breast cancer has experienced tremendous changes in the last half-century. In today's multimodal approach to breast cancer, patients have the prospect of achieving a sense of normalcy after mastectomy thanks to advancements in oncology and breast reconstruction. Although the oncologic management of breast cancer has evolved over multiple centuries, implant-based breast reconstruction (IBBR) has only been around since the 1960s. The last half century has seen the conception of multiple techniques, novel devices, and new possibilities in hopes of achieving outcomes that are similar to or even better than the patient's premorbid state. However, with all these changes, a new problem has arisen-inconsistencies in the literature on how IBBR is described. In this article, we will discuss potential sources of confusion in the IBBR literature and lexicon, highlighting specific terms that may have multiple meanings or interpretations depending on perspective, context, and/or intent. As a first step toward clarifying what we perceive as a muddied landscape, we propose a naming convention for IBBR that centers around four important variables especially pertinent to IBBR-the type of mastectomy performed, the timing of reconstruction, the type of device that is placed, and the pocket location for device placement. We believe that adoption of a more standardized, consistent, and descriptive lexicon for IBBR will help provide clearer communication and easier comparisons in the literature so that we may continue to deliver the best outcomes for our patients.

Skin Reducing Mastectomy and Immediate Tissue Expander Reconstruction: A Critical Analysis

BACKGROUND

Complications of implant-based reconstruction have been shown to be related to increasing body mass index (BMI) and breast size. The impact of skin reducing mastectomy (SRM) with a dermal flap is examined.

METHODS

A retrospective review of a single surgeon's experience with immediate submuscular tissue expander (TE) reconstruction from 2011 to 2019 was performed. The outcomes of SRM were compared with those of skin sparing mastectomy (SSM).

RESULTS

A total of 162 patients (292 breasts) were identified. Mastectomy types were as follows: SRM, 73 (136 breasts) and SSM, 89 (156 breasts). Acellular dermal matrix (ADM) was used to supplement TE coverage in 65.4% of SRM cases. Mean BMI was 29.2 among SRM patients and 25.9 in SSM patients (P < 0.001). Obesity (BMI ≥ 30) was more prevalent in the SRM group (SRM, 38.4% vs SSM, 22.5%; P = 0.03). Mean mastectomy weight was higher in the SRM group (SRM, 833.6 g vs SSM, 425.6 g; P < 0.001). Mean BMI and mastectomy weight were lower in SRM patients who were reconstructed with ADM (ADM, 28.1 vs no ADM, 30.8; P = 0.01; ADM, 746.1 g vs no ADM, 1006.3 g; P < 0.001). Minor complications were more prevalent in the SRM group (SRM, 22.8% vs SSM, 4.5%; P < 0.001). Mastectomy skin flap necrosis (MSFN) was more common in the SRM group (SRM, 22.8% vs SSM, 7.7%; P < 0.001), but MSFN necessitating operative debridement was similarly low in both groups (SRM: 1.9% vs SSM: 4.5%). Major complication rates (SRM 11.0% vs SSM 10.9%) and reconstructive failure rates (SRM 5.9% vs SSM 5.1%) were similar between groups. Mastectomy weight 800 g or higher and BMI of 30 or higher were found to be risk factors for complications on analysis of the SRM cohort (P < 0.05).

CONCLUSIONS

Mastectomy weight and BMI were positive predictors of complications after immediate TE reconstruction. Mastectomy skin flap necrosis is more common after SRM than SSM. The use of SRM with a dermal flap has a similar major complication rate as SSM despite its use in obese, large-breasted women. The dermal flap provides soft tissue coverage, which prevents implant exposure and seroma. The use of ADM does not adversely affect the complication rate of SRM.

Identification of Independent Risk Factors for Skin Complications in a Multifactorial Logistic Regression Analysis of Simultaneous Immediate Autologous Breast Reconstruction and Skin Reduction Mastectomy in Large and Ptotic Breasts Using an Inferiorly Based Deepithelialized Dermal Breast Flap

Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis

BACKGROUND

Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group.

METHODS

Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction.

RESULTS

There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008).

CONCLUSIONS

When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc).

LEVEL OF EVIDENCE

IV. 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 .

Pushing the Envelope: Skin-Only Mastopexy in Single-Stage Nipple-Sparing Mastectomy with Direct-to-Implant Breast Reconstruction

BACKGROUND

Despite advances in skin envelope reduction techniques and experienced nipple-sparing mastectomy flap procedures, the rate of nipple malposition and secondary revision in these patients remains high and eligible candidates are limited. In this article, the authors present a novel technique combining skin reduction nipple-sparing mastectomy surgery with single-stage skin-only mastopexy and direct-to-implant reconstruction.

METHODS

A retrospective review was performed at a single institution from 2015 to 2018. All patients were operated on using this technique consecutively, by a breast and plastic surgeon team (A.F. and A.M.). Surgical technique and outcomes were compared with the currently accepted literature.

RESULTS

Twenty-six patients (40 breasts) underwent this technique; all were single-stage direct-to-implant reconstructions. The average body mass index was 31 kg/m2. A Wise pattern was used in 35 breasts (87.5 percent) and prepectoral placement was used in 25 breasts (62.5 percent). Overall complications included seroma [n = 6 (15 percent)], vertical/T-junction dehiscence [n = 4 (10 percent)], skin necrosis [n = 4 (10 percent)], superficial or partial nipple necrosis [n = 4 (10 percent)], with no total nipple-areola complex lost and no reconstructive failures at 18.7 months' average follow-up.

CONCLUSIONS

In this article, the authors share a novel reconstructive technique in which the skin envelope is reduced, the nipple-areola complex is repositioned, and a direct-to-implant reconstruction is performed in a single stage at the time of mastectomy. Consideration of pearls and pitfalls accompanies a review of the authors' experienced complication profile, and is discussed in the context of current literature.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Breast reconstruction in the high-risk population: current review of the literature and practice guidelines

Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "high-risk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.

Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques

BACKGROUND

Direct-to-implant breast reconstruction continues to grow in popularity among reconstructive breast surgeons and patients alike. Women with large breasts and ptosis are often thought not to be candidates for nipple sparing or direct-to-implant reconstruction. The authors utilized a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy, while the nipple-areolar complex was kept viable on an inferiorly based adipodermal flap in a single stage. They report their experience and outcomes using this approach in women with breast ptosis and/or macromastia.

METHODS

The authors reviewed all direct-to-implant reconstructions with simultaneous nipple-sparing mastopexies performed from June of 2015 to March of 2019. Sixty-five patients and 125 breast reconstructions were analyzed.

RESULTS

Among the 65 patients (125 breast reconstructions), 15 (23 percent) had implants placed in the prepectoral space, and 50 (77 percent) had them placed subpectorally. Forty-seven patients (72 percent) had acellular dermal matrix used. Partial nipple-areolar complex necrosis occurred in six patients (9 percent). Other complications included partial mastectomy flap necrosis (n = 8 patients, 12 percent), implant exposure (n = 3, 4 percent), infection (n = 1, 1 percent), capsular contracture (n = 4, 6 percent), and reoperation (n = 11, 16 percent). Mean follow-up was 17 months (range, 3 to 47 months). There have been no cancer recurrences reported in any participants to date.

CONCLUSIONS

Nipple-sparing mastectomy with mastopexy and immediate direct-to-implant reconstruction dramatically improved the authors' results for implant-based breast reconstruction patients. The higher than expected explantation rate of 7 percent early in the study has since improved. This approach provides an opportunity to expand indications for nipple-sparing mastectomy and direct-to-implant reconstruction to women with breast ptosis and/or macromastia.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Skin-Reducing Mastectomy and Direct-to-Implant Breast Reconstruction With Submuscular-Dermal-Mesh Pocket

BACKGROUND

Despite skin-sparing mastectomy techniques have significantly improved reconstructive options and aesthetic outcomes, patients with large and ptotic breasts remain a challenging group to treat satisfactorily. The Wise-pattern skin-reducing mastectomy (SRM) has been designed for this kind of patients but is not without morbidity. To improve safety, the authors reviewed their experience with a modified SRM and immediate 1-stage implant-based breast reconstruction, using a synthetic absorbable mesh combined with a dermal flap.

METHODS

A retrospective review was undertaken to identify women with medium to large ptotic breast and medium minimally ptotic breast who had undergone SRM and direct-to-implant breast reconstruction using definitive anatomical gel implant, de-epithelialized dermal flap, and absorbable synthetic mesh, between October 2014 and December 2016. Patient demographics were queried, and complication rates, aesthetic outcomes, and patients satisfaction were assessed.

RESULTS

Sixty-two procedures of SRM were performed in 56 patients. Forty-five women received contralateral symmetrization. Twenty-one overall complications occurred in 16 patients. Statistical correlation between risk factors and complications onset was assessed. Body mass index resulted the most substantial risk factor (P = 0.0028) for developing complications, whereas preoperative chemotherapy (P = 0.0050) and comorbidities (P = 0.0117) played a decent role. Smoking attitude (P = 0.1122), age (P = 0.9990), and implant weight (P = 0.1583) did not result as significant risk factors. The reconstructive outcomes were good to excellent in 92.8%, with patient satisfaction ranking very to highly satisfied in 84%.

CONCLUSIONS

The authors' series suggests that SRM with direct-to-implant breast reconstruction can be easily performed when an appropriate SRM pattern is designed, providing complete implant coverage with submuscular-dermal-mesh pocket.

Single-Stage Immediate Breast Reconstruction Using Anatomical Silicone-Based Implant and The Hammock Technique of Dermal-Muscle Flap in Large and Ptotic breasts: A Multicenter Study

BACKGROUND

This study revisits the previously described technique of inverted-T skin-reducing mastectomy and dermal-muscle pocket as a single-stage breast reconstruction using anatomical implants in large and ptotic breasts. Refinements have been added to enhance the quality of implant coverage, improve aesthetic outcome, and augment the implant volume than previously described in the literature.

SUBJECTS AND METHODS

The study was performed in three centers in the UK, Egypt, and Libya. It included patients with large ptotic breasts with a breast cup size of D or larger. The areola-to-inframammary fold distance is of 8 cm or more, and a nipple-sternal notch distance is 25 cm or more. Modification of the dermal-muscle flap was made through dividing the medial and lateral ends of the de-epithelialized flap at a distance of one inch to create wings that could be sutured to the free edge of pectoralis major muscle to act as a hammock.

RESULTS

It included 42 patients, and the mean age of the patients was 44.4 years (range 28-62). The mean body mass index was 34.2 (range 24-42). The reconstruction was unilateral in 32 (76.2%) patients and bilateral in ten (23.8%) patients. The average implant volume was 498.5 CC (range 375-650). Seventeen (40.5%) patients had a symmetrizing breast reduction. The average follow-up time was 52 weeks. Major complications were noticed in four (7.7%) breasts: Three breasts had major skin necrosis and one breast had hematoma that necessitated surgical evacuation. There were no reported cases of implant extrusion. Minor complications were recorded in six (11.5%) breasts; two had wound infection, and three had minor skin necrosis.

CONCLUSION

The hammock technique of dermal-muscle flap is safe and versatile in large and ptotic breasts. It also creates a natural-looking breast with bigger implants.

Quality of Life after Bilateral and Contralateral Prophylactic Mastectomy with Implant Reconstruction

Background

Prophylactic mastectomy is an effective approach to breast cancer risk reduction in patients at high risk. Further studies using standardized measures for quality of life are needed to better understand the effect of prophylactic mastectomy on individual patients and, thereby, allow for better patient counseling and selection.

Methods

In this prospective study patients undergoing bilateral mastectomy were asked to complete the BREAST-Q questionnaire before and 1 year after surgery. All patients underwent bilateral mastectomy with implant-based breast reconstruction. Patient- and surgery-related information was collected in a database.

Results

In total, 48 patients underwent bilateral skin-sparing mastectomy. Of these, 29 (60.4%) suffered from breast cancer. A 2-stage reconstruction with intermediate expander implantation was conducted in 19 (39.6%) patients. All patients completed the BREAST-Q questionnaire. The domain "psychosocial well-being" was significantly improved from a mean score of 74.98 preoperatively to a postoperative score of 81.56 (p = 0.021). In contrast, the domain "physical well-being" dropped -8.38 points on average to a postoperative score of 74.96 (p < 0.001). Interestingly, patients with the lowest preoperative score in the domain "satisfaction with breast" showed the greatest increase after surgery (50.31 vs. 67.25, p < 0.001). On the contrary, patients with the highest preoperative values experienced the strongest decrease in satisfaction (91.60 vs. 75.27, p = 0.012).

Conclusion

Implant-based prophylactic mastectomy leads to good quality-of-life results in patients at high risk for breast cancer. Especially, patients with a low preoperative satisfaction with their breasts have a significantly higher chance of experiencing substantial improvements in their quality of life.

Deepithelialized Skin Reduction Preserves Skin and Nipple Perfusion in Immediate Reconstruction of Large and Ptotic Breasts

BACKGROUND

Women with large and/or ptotic breasts are often not considered candidates for nipple-sparing mastectomy (NSM) and/or immediate breast reconstruction given difficulties avoiding ischemic complications and achieving a favorable aesthetic result. We report a novel technique involving deepithelialized skin reduction to simultaneously reduce the skin envelope and preserve perfusion to the skin and nipple in immediate breast reconstruction for women that fit this high-risk anatomic profile.

METHODS

We reviewed cases of NSM and skin-sparing mastectomy (SSM) with immediate implant-based and free autologous reconstruction by a single plastic surgeon from 2013 to 2017. All patients had at least size C cup breasts (>500 g) and/or grade 3 ptosis. Select patients undergoing NSM had devascularization of the nipple-areolar complex (NAC) 1 to 2 months before surgery to promote adaptive circulatory change. After mastectomy, skin reductions were performed via Wise, periareolar, or circumareolar reduction patterns, with infolding of a deepithelialized inferior and periareolar skin flap over a tissue expander or free flap. In NSM, the nipple was advanced superiorly and redirected through a keyhole of deepithelialized skin flap.

RESULTS

Patients had an average age of 43.6 years and body mass index of 27.7. A total of 33 breasts in 19 patients (14 bilateral, 5 unilateral) underwent deepithelialized skin reduction. There were 14 NSM and 19 SSM. Reconstructions consisted of 13 tissue expanders exchanged to implants and 20 abdominally-based free flaps. Four patients underwent devascularization of the NAC before NSM. Six (18%) breasts had partial thickness flap loss that healed by delayed primary (n = 1) or secondary (n = 5) intention. Four nipples, all in patients without prior NAC devascularization, had ischemic complications (2 epidermolysis, 12.5%; 2 partial necrosis, 12.5%), which all healed by secondary intention with the exception of 1 case of NAC removal.

CONCLUSIONS

Skin reduction with deepithelialization and tissue infolding preserves dermal plexus perfusion and promotes nipple and skin flap survival in immediate implant-based and autologous breast reconstruction after SSM and NSM. This technique can be combined with NAC devascularization to further promote nipple perfusion. Overall, this method offers an acceptable complication rate and the potential to expand the reconstructive options available to women with large and/or ptotic breasts.

The Bell Pattern: A Novel Breast Incision Approach to Skin-Reducing Mastectomies

Background

As immediate direct to permanent implant-based breast reconstruction (IBBR) continues to gain in popularity, surgeons seek to apply these techniques to patients with large or ptotic breasts. A new bell pattern skin excision is described and limits major complications in this high-risk population.

Objective

The authors describe a novel skin excision pattern for patients with large or ptotic breasts who desire IBBR and assess its safety. The authors also evaluated the ability of the pattern to account for intraoperative developments.

Methods

This retrospective analysis of a single surgeon’s experience included 17 consecutive patients (31 breasts) with large or ptotic breasts undergoing skin-reducing mastectomy with attempted utilization of the bell pattern approach and IBBR with acellular dermal matrix.

Results

Mean age was 50 years, mean body mass index was 27.4 kg/m², and mean breast specimen weight was 683 g. A bell pattern excision was planned for all breasts preoperatively. Three breasts (10%) required an alternative closure pattern due to intraoperative ischemia (n = 1), or additional oncologic resection (n = 2). The pattern successfully accommodated flap ischemia in 8 (26%) other breasts. After a median follow-up of 5.1 months, the number of bell pattern breasts with major and minor complications was 0 (0%) and 9 (32%), respectively. The most common minor complication was seroma (n = 5, 18%), and minor incision wound (n = 3, 11%). There were no reconstruction failures utilizing the bell pattern.

Conclusion

The bell pattern approach is a safe and adaptable alternative to traditional skin-reducing mastectomy in patients with large or ptotic breasts.

Level of Evidence: 4

Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix

BACKGROUND

The inverted T (Wise pattern) mastectomy for patients with macromastia or significant breast ptosis has evolved along with generalized techniques for breast reconstruction. We present a review of Wise pattern breast reconstruction along with our technique for direct to implant reconstruction using dermal matrix.

METHODS

The literature was reviewed and an analysis of techniques and complications was performed. We present our series of patients incorporating dermal matrix and relatively large implants in direct to implant reconstruction.

RESULTS

Of 18 breasts reconstructed only 2 failed. One caused by flap necrosis secondary to smoking and one as a result of preoperative radiation.

CONCLUSION

Wise pattern breast reconstruction using relatively large implants and dermal matrix in direct to implant reconstruction is a safe technique in selected patients with macromastia.

Complications, patient-reported outcomes, and aesthetic results in immediate breast reconstruction with a dermal sling: A systematic review and meta-analysis

An inferior dermal flap ("sling") can be used to cover an implant with two layers of tissue following Wise pattern skin-reducing mastectomies. Here, we performed a systematic review of the risks and benefits of this technique, specifically regarding complications, patient-reported outcomes, and aesthetic outcomes. PubMed and other relevant databases were searched using specific key words, with inclusion criteria comprising studies of dermal sling use involving ≥ 5 patients and performance according to the PICO framework. A meta-analysis was performed using a random-effects model involving a binomial distribution with logit-link function. For each study, the 95% confidence interval (CI) was obtained based on exact limits from a binomial distribution, and heterogeneity testing was performed using a chi-squared test. A total of 428 abstracts were retrieved, with 24 studies meeting the inclusion criteria and including a total of 879 patients and 1184 reconstructed breasts. The mean complication rate was 21.6% (95% CI: 16.9-27.2%), with the most common complication involving wound-healing problems (mean, 11.4%; 95% CI: 8.5-15.2%), and the frequency of implant loss (< 3 months) varied from 0% to 14% (mean, 2.2%; 95% CI: 1.1-4.4%). Seven articles reported patient-reported outcomes, and four reported aesthetic outcomes, with the quality of evidence classified as low for complications and very low for patient-reported outcomes and aesthetic outcomes. Our findings showed that although implant-based reconstruction with a dermal sling is widely used, there is little scientific evidence supporting the method.

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.

Breast reconstruction with a dermal sling: a systematic review of surgical modifications

A dermal sling (DS) is used to cover the implant with two layers of tissue when immediate breast reconstruction is performed in women with large and ptotic breasts. It works as an autologous acellular dermal matrix/mesh that can be used to control the implant pocket and inframammary fold, without inferring an extra foreign material and higher costs. There is relatively little published about the DS technique. The primary aim of this study was to systematically review published surgical modifications to the dermal sling (DS). The secondary aim was to investigate what implants have been used. Relevant databases were searched for articles and abstracts published between January 1990 and September 2018. Inclusion criteria were studied and case reports on DS meeting the criteria defined in a PICO. Review articles were excluded. Total evidence for the different types of DSs was graded according to GRADE. A total of 428 abstracts were retrieved. Of these 373 abstracts did not meet the inclusion criteria and were excluded, leaving 54 abstracts. Nine categories of surgical modifications could be identified: classic dermal sling (DS) with minor modifications, non Wise-pattern mastectomy DS, nipple areola complex bearing DS, DS in combination with a matrix/mesh, DS as a suture line protection technique, DS with a modified circulatory basis, DS without an implant, DS as an immediate-delayed technique and pre-pectoral DS. The evidence for DS as a surgical technique is very low (GRADE ⊕). The DS can be used with both permanent implants and tissue expanders (GRADE ⊕).

A Simple Flap Design for the Salvage of Immediate Implant-Based Breast Reconstruction

BACKGROUND

Breast reconstruction with implants is a real challenge in patients with large breast volume. Skin-reducing inverted-T mastectomy is the best solution for these patients. Delayed wound healing or necrosis at the T-junction area can be seen in this procedure, although it may also lead to severe conditions such as the exposure and loss of implant. In this article, the use of local pedicled flap for the management of these situations was discussed.

METHODS

Between April 2010 and July 2015, 54 patients underwent breast reconstruction by inverted-T skin-reducing mastectomy and immediate implant-based breast reconstruction at our clinic. During the postoperative follow-up period, necrosis at the T-junction area was observed in 8 patients. All the patients received proper wound care, and the necrosis was surgically debrided. The defect was closed with Limberg-like rectangular flap.

RESULTS

The mean age was 45.2 (range, 33-54) years. The mean body mass index was 25.57 ± 6.53 (range, 21.2-35.2) kg/m. The mean follow-up was 10.9 (range, 4-19) months. Two patients had implant exposure at the defect site after the debridement. There was no implant loss in any of the patients.

CONCLUSIONS

The Limberg-like rectangular flap can be used as a salvage option in complicated skin-reducing mastectomies and can be considered as a safe and effective method because of its easy-to-use nature, low cost, and no need for microsurgery experience.

Comparing morbidity rates between wise pattern and standard horizontal elliptical mastectomy incisions in patients undergoing immediate breast reconstruction

BACKGROUND

Breast cancer patients with ptotic breasts pursuing mastectomy with immediate reconstruction can present challenges. A wise pattern (inverted-T) mastectomy incision (WPM) has been suggested as an alternative to the standard horizontal elliptical mastectomy (EM) to reduce redundant skin and correct ptosis. Herein, we sought to examine the differences in morbidity between the two techniques.

METHODS

We performed a retrospective review of women undergoing mastectomy with immediate reconstruction at our institution from June 2007 to January 2016. We compared those undergoing WPM to a control population undergoing EM. Statistical analysis was performed evaluating clinical, pathological, and surgical outcome variables according to patient and per breast. All tests were two-sided with alpha level set at 0.05 for statistical significance.

RESULTS

A total of 241 women underwent mastectomy and reconstruction in 421 breasts; 78/241 (32%) had WPM (149 breasts), 163/241 (68%) had EM (272 breasts). Both groups were similar in age, smoking status, diabetes, race, tumor type, and pathologic stage (all P > 0.07). Skin flap necrosis was the most frequently encountered complication, occurring in 58/149 (38.9%) of WPM breasts and in 24/272 (8.9%) of EM breasts (P < 0.0001). There was no difference in the need for revisional procedures between the groups (WPM: 24.1% vs EM: 17.6%, P = 0.207).

CONCLUSION

Patients should be counseled WPM is associated with higher rates of skin flap necrosis. However, this does not translate into higher rates of revisional procedures or return to OR.

Combination of acellular dermal matrix with a de-epithelialised dermal flap during skin-reducing mastectomy and immediate breast reconstruction

Introduction Patients with large ptotic breasts undergoing immediate implant-based reconstruction often require skin-reducing mastectomy to optimise the aesthetic outcome. However, healing complications, especially at the resulting inverted T-junction, leading to wound dehiscence, infection, skin necrosis, implant exposure and failed reconstruction have been widely reported. We present an innovative approach for immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling to protect and support the implant, while improving clinical outcomes in this challenging group of patients. Materials and methods Demographic, tumour and surgical data were reviewed for patients undergoing Wise pattern (T-scar) skin-reducing mastectomies with immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling. Results This technique was successfully employed to reconstruct five large pendulous breasts in four breast cancer patients with a median age of 50.5 years (range 34-61 years) who were not suitable for, or had declined, flap-based reconstruction. The acellular dermal matrices used were SurgiMend®, StratticeTM and Braxon® and the expandable implants were placed in the sub-pectoral (n = 3) and pre-pectoral (n = 1) planes. The technical steps and clinical outcomes are presented. One patient experienced T-junction breakdown overlying the de-epithelialised dermis without implant loss. Conclusion The combination of an acellular dermal matrix and a dermal sling provides a double-layer 'water-proofing' and support for the implants inferiorly, avoiding T-junction breakdown complications, since any dehiscence is on to well-vascularised dermis. Furthermore, the acellular dermal matrix stabilises the implant in the large mastectomy cavity (pocket control). This approach provides a viable option which facilitates mastectomy and immediate implant reconstruction in large-breasted patients.

Dual plane breast implant reconstruction in large sized breasts: How to maximise the result following first stage total submuscular expansion

Introduction

Women who were good candidates for a skin reducing mastectomy, but were instead treated with a skin-sparing mastectomy and reconstruction with expanders, show discrepancy of volume and form between the healthy breast (voluminous and ptotic) and the expanded mastectomy envelope and muscle, which has a smaller size as well as excessive amount of skin at the lower pole.

Methods

From January 2014 to March 2015, we recruited 18 women with breasts of medium to large volume and with moderate to severe ptosis, already treated at a different centre with a one-side mastectomy and reconstruction by means of an expander. These women were treated at our unit for the second reconstructive step with a dual plane technique and a contralateral reduction/mastopexy.

Results

The minimum duration of follow-up was 2 years (range 24–30 months). The average volume of the implants was 613 g. The reconstructive outcome at the final follow-up (at least 24 months) was judged by the specialist as excellent in 5 cases, very good in 10 cases and good in 3 cases. Breast Q average score was 87.08.

Discussion

The disinsertion of the expanded muscle dome and the use of a dual plane technique for the placement of the definitive implant provide a solution to the skin-volume mismatch problem. The subcutaneous placement of the implant at the level of the lower pole extends the excessive amount of skin and gives the reconstructed breast fullness and natural ptosis. Further validation of our results is needed.

The inframammary skin-sparing mastectomy technique

Skin-sparing mastectomy and immediate implant-based breast reconstruction is technically a challenging procedures for women with large, ptotic breasts. This is usually performed using the Wise pattern incision resulting in an inverted T scar, which is associated with postoperative complications. The other challenge is obtaining adequate coverage of the prosthesis. We describe a technique that avoids the inverted T scar and provides a single horizontal scar with a double dermo-muscular layer coverage of the prosthesis.

Optimizing Patient Selection for Direct-to-Implant Immediate Breast Reconstruction Using Wise-Pattern Skin-Reducing Mastectomy in Large and Ptotic Breasts

BACKGROUND

Immediate breast reconstruction in large and ptotic breasts is challenging, often requiring skin-reducing procedures. The Wise-pattern skin-reducing mastectomy (WPSRM) technique provides reliable one-stage implant coverage using the pectoralis muscle and a de-epithelialized inferiorly based dermal flap. However, de-vascularization may result in mastectomy skin flap necrosis. We aimed to critically evaluate and isolate patients at high risk of complications using this procedure.

METHODS

We retrospectively reviewed consecutive patients undergoing WPSRM by the senior author from January 2008 to December 2011. Data collected included patient demographics, breast cancer staging, smoking, preoperative radiation, chemotherapy, BMI, mastectomy weight, implant size and type. We analyzed their effect on complications, revisions and failure rate.

RESULTS

Fifty-nine WPSRMs were performed in 39 patients with a minimum of 12-month follow-up. Complications occurred in 43.75% patients and 34.88% breasts. Multivariate statistical analysis revealed that age (p = 0.093) and BMI (p = 0.631) were not significant risk factors as opposed to previously published data. Mastectomy weight was significantly associated with major complications requiring secondary surgery (odds ratio per 100 g of breast tissue was 1.18; 95% CI 1.01-1.39; p = 0.036) as 90.5% of our complications occurred in those patients with mastectomy weight exceeding 700 g. Complications were reduced twofold when selecting a Becker adjustable implant over a silicone one for these higher mastectomy weights.

CONCLUSION

WPSRM was found to be associated with an increased complication rate in patients with high mastectomy weights and immediate reconstruction with silicone implants. We propose an algorithm offering better patient selection for this technique in immediate breast reconstruction.

LEVEL OF EVIDENCE V

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 .

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

Becker Expander-Based Breast Reconstruction Following Wise Pattern Skin-Reducing Mastectomy: Complication Rates and Risk Factors

Our aim is to analyze the results of immediate breast reconstruction in women with macromastia after skin-reducing mastectomy (SRM), with an emphasis on complications and risk factors. Between 2008 and 2013, fifty women with hypertrophic breasts, aged 21-74 years, underwent immediate expander-based breast reconstruction after Wise pattern SRM. An inferiorly based de-epithelialized skin flap was sutured to the inferolateral border of the pectoralis major muscle and covered the expander. Thirty-five women had a unilateral and fifteen a bilateral procedure (total 65 breasts). In all cases, Becker-35 expanders of volume ranging from 365 to 685 cc were used. Risk factors (BMI, smoking, expander's size, preoperative irradiation, chemotherapy) and complications were recorded. Follow-up up to 60 months was compiled. In all cases, the myodermal pouch provided safe coverage and support of the expander. Postoperative complications occurred in 18 out of 65 breasts (27.6%) and included skin ischemia in 11 breasts (16.9%), late infection in two (3%), seroma and expander rotation in four and one, respectively (6.1 and 1.5%), and severe peri-prosthetical contraction in five breasts (7.6%). Statistical analysis showed that complications were significantly related to preoperative radiotherapy and smoking; no significant correlation was documented between complication rates and chemotherapy, BMI, age or expander's size. We suggest that the inverted-T SRM, creating a combined "myodermal" flap for the coverage of a Becker expander, is a useful single-stage reconstructive option for patients with macromastia. Preoperative radiotherapy is significantly related to higher postoperative complication rates, and may result in a less optimal reconstructive outcome. Level of Evidence V 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.

Partial Breast Reconstruction with Goldilocks Technique After Excision of Giant Fibroadenoma: A Case Report

Giant juvenile fibroadenomas are relatively rare, accounting for less than 1% fibroadenomas. Large breast tumors create significant asymmetry and provide unique reconstructive challenges after removal. In this case, we describe a 21-year-old female with delayed presentation of a giant fibroadenoma of the right breast. This represents an unusual presentation of benign breast disease requiring reduction of the skin envelope, extensive glandular resection, lower pole reconstruction, and free nipple grafting to achieve symmetry with the opposite breast. A novel modification of the Goldilocks mastectomy technique is described for partial breast reconstruction. Adaptation of the Goldilocks mastectomy technique provides adequate soft tissue for partial breast reconstruction. Using the lower pole deepithelialization breast skin flap provides autologous vascularized tissue to supplement volume loss after tumor and glandular excision. Benign breast disease can create significant breast deformities. Application and combination of the Goldilocks mastectomy technique allow for partial breast reconstruction without the need for an additional donor site or prosthetic devices.

Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction - A prospective randomized trial

BACKGROUND

Comparative studies on the use of meshes and acellular dermal matrices (ADM) in implant-based breast reconstruction (IBBR) have not yet been performed.

METHODS

This prospective, randomized, controlled, multicenter pilot study was performed at four Austrian breast cancer centers. Fifty patients with oncologic or prophylactic indication for mastectomy and IBBR were randomized to immediate IBBR with either an ADM (Protexa(®)) or a titanized mesh (TiLOOP(®) Bra). Complications, failed reconstruction, cosmetic outcome, patients' quality of life and the thickness of the overlying tissue were recorded immediately postoperatively and 3 and 6 months after surgery.

RESULTS

48 patients participated in the study (Protexa(®) group: 23; TiLOOP(®) Bra group: 25 patients). The overall complication rate was 31.25% with similar rates in both groups (Protexa(®) group: 9 versus TiLOOP(®) Bra group: 6; p = 0.188). There was a higher incidence of severe complications leading to failed reconstructions with implant loss in the Protexa(®) group than in the TiLOOP(®) Bra group (7 versus 2; p < 0.0001). An inverted T-incision technique led to significantly more complications and reconstructive failure with Protexa(®) (p = 0.037, p = 0.012, respectively). There were no significant differences in patients' satisfaction with cosmetic results (p = 0.632), but surgeons and external specialists graded significantly better outcomes with TiLOOP(®) Bra (p = 0.034, p = 0.032).

CONCLUSION

This pilot study showed use of TiLOOP(®) Bra or Protexa(®) in IBBR is feasible leading to good cosmetic outcomes and high patient satisfaction. To validate the higher failure rates in the Protexa(®) group, data from a larger trial are required. NCT02562170.

Risk-reducing, conservative mastectomy-analysis of surgical outcome and quality of life in 272 implant-based reconstructions using TiLoop(®) Bra versus autologous corial flaps

BACKGROUND

Different approaches have evolved for conservative mastectomies, mostly according to surgeon's preference. Patients' perspective was not always in the primary focus. BRCA status has drawn much attention and therapeutic as well as prophylactic mastectomies are rising. However, knowledge on quality of life (QoL) thereafter is limited. We investigated the surgical and patient reported outcome of conservative mastectomies with implants and TiLoop(®) Bra vs. corial flaps.

METHODS

Conservative mastectomies were analyzed from a prospectively maintained database in a unicentric study of consecutive 272 reconstructions from 2000-2014. We used four validated QoL questionnaires: FACT-G, EORTC C-30, EORTC B-23 and Breast Cancer Treatment Outcome Scale (BCTOS). The use of TiLoop(®) Bra, a titanized polypropylene mesh, for lower breast pole coverage was compared to autologous corial flaps.

RESULTS

A total of 217 patients with 272 conservative mastectomies (55 bilateral) were included. Median follow-up was 3.5 years (range, 0-14 years). Skin-sparing mastectomy (SSM) was performed in 131 patients and subcutaneous mastectomy (SCM) in 86 patients. Invasive breast-cancer was the indication for surgery in 106 patients, non-invasive breast cancer (DCIS) in 80 patients, prophylactic indication (BRCA1/2-mutation) in 30 patients and contralateral alignment in 1 patient. TiLoop(®) Bra was used in 78 and corial flap in 79 patients. Response to questionnaires was 70%. TiLoop(®) Bra improved aesthetic results (P=0.049) and prevented implant dislocation (P=0.009). All patients expressed their adherence to the decision for surgery. Patients with SCM expressed their satisfaction even to a higher extent than those with SSM, particulary with regard to symmetry (P=0.018) and scars (P=0.037).

CONCLUSIONS

QoL after conservative mastectomies is demonstrated as excellent in several validated QoL-instruments. Double-plane technique for coverage of the implant yields good results with autologous corial flaps and Tiloop(®) Bra, favouring the latter in terms of aesthetics and prevention of implant dislocation.

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

BACKGROUND

Patients with large or ptotic breasts undergoing mastectomy followed by tissue expander/implant-based reconstruction may benefit from a Wise (inverted-T) pattern reduction mammaplasty incision compared with the traditional horizontal elliptical incision. The authors compared these two groups of patients with regard to complication rates and outcomes.

METHODS

Sixty-nine patients (117 breasts) were identified who underwent Wise pattern mastectomy and two-stage reconstruction. A control group of 89 patients (136 breasts) who underwent reconstruction after horizontal elliptical mastectomy were selected over the same period. Patient demographics, clinical characteristics, and complication rates were recorded and analyzed statistically.

RESULTS

Patient demographics (age, body mass index, diabetes, smoking, and irradiation history) and clinical characteristics (laterality, expander size and fill volume, and time to expansion) were similar, with the exception of body mass index (control, 26.7 kg/m; inverted-T, 28.7 kg/m; p = 0.04) and mean intraoperative fill volume (control, 158.7 cc; inverted-T, 196.9 cc; p = 0.02). Of all complications (infection, seroma, flap necrosis, expander loss, and salvage), only the rate of mastectomy flap necrosis was significantly greater (p = 0.002) in patients undergoing inverted-T mastectomy (25.6 percent versus 11.0 percent). This difference did not result in a significantly higher rate of expander loss or need for salvage surgery.

CONCLUSIONS

The inverted-T mastectomy approach can be performed safely with acceptable complication rates. When compared with an internal control group, complication rates were similar, with the exception of mastectomy flap necrosis. Despite a higher rate of flap necrosis, 91 percent of inverted-T patients successfully completed the expansion process.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Skin sparing/skin reducing mastectomy (SSM/SRM) and the concept of oncoplastic breast surgery

INTRODUCTION

With the better understanding of breast cancer history and biology, improved diagnostic modalities and the shift towards minimally invasive surgeries, indications for prophylactic mastectomy, skin sparing or skin reducing mastectomies (SSM/SRM) with nipple areolar complex (NAC) preservation coupled with immediate breast reconstruction are gaining popularity. The authors share their experience and conception with mastectomy and immediate alloplastic breast reconstruction with the esthetic circumvertical mammoplasty pattern combined with the dermal barrier buttress flap.

MATERIAL AND METHODS

The described technique was performed for 28 patients presenting for mastectomy and immediate alloplastic breast reconstruction. With close collaboration between the oncologic and plastic surgeons, mastectomy was performed in all cases with the esthetic circumvertical mammoplasty pattern. To achieve safe excision and optimal reconstruction, the standard incisions could be custom designed to fit oncologic requirements and allow the creation of a dermal barrier flap used as a buttress separating the implant from the suture line.

CONCLUSION

The circumvertical mastectomy pattern combined with the dermal barrier buttress flap is a versatile option allowing safe reconstruction regardless of the tumor and necessary skin excision location.

Augmentation mastopexy: maximal reduction and stable implant coverage using four flaps

BACKGROUND

A single-stage operation to correct ptotic and hypoplastic breasts would appear to be a very appealing option for both surgeons and patients. However, this procedure is the most often litigated in aesthetic surgery because of its frequent complications. Our goal in this article is to report our experience with a four-flap technique for implant coverage in maximum reduction mastopexy with prosthesis.

METHODS

From January 2011 to March 2013, a total of 41 patients with Regnault grade II or grade III ptosis with no hypertrophy underwent primary bilateral augmentation mastopexy. Our technique includes an inverted-T mastopexy and a thin, well-vascularized, inferior dermoglandular flap to cover the inferior pole of the implant. Retrospective data collection revealed a mean patient age of 37.5 years. Thirty-nine patients were treated with round cohesive silicone gel implants and two with anatomical cohesive gel implants. The mean implant volume was 280 cc and mean follow-up time was 14 months.

RESULTS

The following complications were observed in declining frequency: four suture dehiscences, two hematomas, one capsular contracture, one implant malposition, and one poor scarring. A satisfaction questionnaire revealed very high satisfaction in 23 patients (56.09 %), high satisfaction in 12 (29.26 %), moderate satisfaction in four (9.75 %), and low satisfaction in two (4.87 %).

CONCLUSIONS

Our results demonstrated a low complication rate (21.9 %) and low reoperation rate (12.1 %) with our technique and make us confident in recommending this technique for grade II and grade III ptosis.

LEVEL OF EVIDENCE V

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 at www.springer.com/00266 .

Breast reconstruction using de-epithelialized dermal flap after vertical-pattern skin-sparing mastectomy in macromastia

INTRODUCTION

Prophylactic mastectomy is performed to reduce the risk of breast cancer in high-risk conditions, and expectations about reconstruction are too high. Implant coverage with healthy tissue and skin reducing as an envelope are two concerns in the treatment of macromastia cases. We present our results obtained with a prosthetic reconstruction technique using an inferior pedicled de-epithelialized dermal flap after vertical-pattern skin-sparing mastectomy in this retrospective study.

METHODS

Fourteen patients with macromastia and with a high risk of breast malignancy were treated with breast prosthesis using an inferior pedicled de-epithelialized dermal flap after vertical-pattern skin-sparing mastectomy, and were followed for 6 months to 2 years.

RESULTS

Good aesthetic results were obtained in all of the patients with increased patient satisfaction. There were no serious complications and the patients were all satisfied.

DISCUSSION

Since there is no dangerous T-point in vertical-pattern skin-sparing mastectomy in contrast to an inverted-T wise-pattern technique, where flaps are connected under great tension and susceptible to separation, it can be used safely in macromastia cases, as in smaller breasts. In addition, a de-epithelialized dermal flap is quite useful to cover the inferior pole of the prosthesis and it eliminates the need for an acellular dermal matrix.

The effects of breast size in unilateral postmastectomy breast reconstruction

BACKGROUND

Postmastectomy breast reconstruction is offered to women with breast cancer regardless of body habitus and breast size. The decision regarding technique for breast reconstruction includes patient preference, risk factors, and physical characteristics. The purpose of this study was to determine whether there is a relationship between preoperative breast size and choice of reconstruction, choice of contralateral breast symmetry procedure, and incidence of complications.

METHODS

A retrospective review of 355 patients who underwent unilateral breast reconstruction at Emory University from 2005 to 2009 was performed. Patients were stratified into 3 groups based on mastectomy specimen weight with small breasts defined as less than 500 g, medium breasts as 500 to 1000 g, and large breasts as more than 1000 g. Patient demographics were queried including age and risk factors. Additional data points included type of reconstruction, contralateral procedure, and complications.

RESULTS

There were 144 patients with small breasts (40.5%), 150 with medium breasts (42.1%), and 62 with large breasts (17.4%). Women with small breasts were equally likely to undergo tissue expander (34%), latissimus dorsi flap (32%), or TRAM/DIEP flap (34%) reconstruction. Women with medium breasts were most likely to undergo TRAM/DIEP reconstruction (47%), whereas women with large breasts were most likely to undergo latissimus dorsi reconstruction (37%; P = 0.134). Small-breasted women were more likely to undergo contralateral augmentation (P < 0.0001), which varied based on the type of reconstruction. Women with medium-sized breasts were more likely to undergo mastopexy (P = 0.033), and large-breasted women were more likely to undergo reduction (P < 0.0001). Women with complications had a greater mean mastectomy weight than women without complications (744 g compared with 620 g, P = 0.0062), and there was an increasing incidence of postoperative wound infections with increasing breast size (18% of large breasts, 7% of medium breasts, and 3% of small breasts; P = 0.0003).

CONCLUSIONS

Preoperative breast size does play a role when choosing the most appropriate reconstructive option and symmetry procedure. Being able to adjust the contralateral breast, however, brings the extremes of breast size toward the middle, making most options available regardless of initial size and shape. There are noticeable trends in technique and outcome when stratified by breast size.