Staged wise-pattern skin excision for reconstruction of the large and ptotic breast. Plast Reconstr Surg. 2010;126:1831-1839. [PMID: 21124123 DOI: 10.1097/prs.0b013e3181f5278f]

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.

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 Batwing Mastopexy in Immediate Implant-based Breast Reconstruction: An Aesthetic Enhancement For Cancer Patients"

BACKGROUND

Historically, many patients with breast ptosis have been excluded from nipple-sparing mastectomies (NSM). By performing mastopexy at the time of immediate reconstruction, more ptotic patients can be considered for NSM. We review our experience of simultaneous batwing mastopexy performed at the time of immediate implant-based reconstruction.

METHODS

A retrospective chart review identified patients who underwent immediate implant-based breast reconstruction from 2015 to 2020 at a single institution. The patients were divided into two cohorts, batwing mastopexy and standard reconstruction (no mastopexy) and compared.

RESULTS

A total of 324 breast operations in 188 patients were included (80 concurrent batwing and 244 standard implant-based reconstructions). Patient demographics were similar for both groups, except patients in the batwing group had greater ptosis, while more patients in the standard group underwent adjuvant chemotherapy. Mean follow-up was 15.9 months (range 3.19 to 55.20 months). Complications rates were comparable in the batwing and standard groups with no statistically significant differences in rates of hematoma (1.3% vs 3.3%; p=0.34), seroma (5.0% vs 8.2%; p=0.34), major infection (8.8% vs 9.0%;p=0.94), skin/nipple necrosis (6.3% vs 11.5%; p=0.18) and explantation (11.3% vs 14.8%; p=0.43). Rate of minor infections was higher in the group with concurrent batwing mastopexy (10.0% vs 3.7%; p=0.03).

CONCLUSION

We demonstrate that simultaneous batwing mastopexy can be safely performed at the time of immediate breast reconstruction. In our experience, this technique provides comparable complication rates, improves aesthetic outcomes in patients with significant ptosis or macromastia and allows NSM to be an option for those who would otherwise be excluded.

Prepectoral versus Subpectoral Tissue Expander Breast Reconstruction: A Historically Controlled, Propensity Score-Matched Comparison of Perioperative Outcomes

BACKGROUND

The rising popularity of prepectoral tissue expander placement with acellular dermal matrices in immediate breast reconstruction has prompted many studies on the safety of this technique. However, a comprehensive propensity-matched, historically controlled trial comparing perioperative outcomes following prepectoral versus partial subpectoral (dual-plane) placement of tissue expanders is lacking.

METHODS

Retrospective propensity-matched cohort analysis was performed on all patients of two senior reconstructive surgeons who underwent bilateral tissue expander placement following a mastectomy with one of three breast surgeons at a single academic institution from 2012 onward (n = 260). Two matched groups (prepectoral and partial subpectoral) each consisted of 102 patients. Univariate and multivariable analyses were also performed to contextualize the risks associated with prepectoral reconstruction relative to demographic characteristics and other clinical factors.

RESULTS

Compared to dual-plane subpectoral placement, prepectoral placement resulted in similar rates of overall perioperative complications (32 percent versus 31 percent; p = 1.00) and perioperative complications that required operative treatment (21 percent versus 21 percent; p = 1.00). There were no significant differences between the groups in complication rates for hematomas, seromas, impaired wound healing, and infection. Although prepectoral placement was associated with prolonged time to drain removal, those patients completed the expansion process twice as fast, were expanded further in the operating room, and were more than twice as likely to forgo clinic-based expansion. Prepectoral reconstruction was not associated with increased risk for any complications in univariate or multivariable analysis.

CONCLUSIONS

Prepectoral tissue expander placement permitted greater intraoperative filling of expanders and a reduced likelihood of clinic-based expansion, with no increase in adverse outcomes compared to partial subpectoral placement. Adoption of this technique may reduce unnecessary clinic visits; shorten the delay before adjuvant therapy; and minimize patient apprehension, pain, and discomfort related to clinic-based expansion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Bipedicled Nipple-Sparing Mastectomy Versus Traditional Nipple-Sparing Mastectomy: Comparison of 2 Alternative Techniques in Order to Save Nipple-Areola Complex

BACKGROUND

Nipple-areola complex-sparing mastectomy (NSM) represents, when a mastectomy is unavoidable, the best treatment possible that can be offered to attenuate the negative impact of surgery on patients' quality of life. Unfortunately, NSM can be used only in selected patients with small and nonptotic breasts. In order to save the nipple-areola complex (NAC) also in patients with large and ptotic breast, otherwise subjected to a skin-sparing mastectomy with the sacrifice of the NAC, we described the bipedicled nipple-sparing mastectomy (BNSM). The aim of this study is to obtain a formal outcome assessment of BNSM and analyze the complications rate of this technique compared with traditional NSM. We furthermore attempt to describe the surgical procedures present in the literature that allow to preserve NAC also in large and ptotic breasts presenting the complication rates observed and comparing with our technique. Aesthetic outcome has also been evaluated.

METHODS

We retrospectively reviewed 42 procedures of consecutive patients undergoing immediate reconstruction with tissue expanders after NSM (20 patients) or BNSM (19 patients). We divided them in 2 groups focused on surgical complications and aesthetic outcome.

RESULTS

On a total of 42 procedures, the principal major complication was dehiscence of surgical wound procedures needing 1-day surgery revision occurring in 3 (14.3%) of the BNSM group and 1 (4.8%) of the NSM group, whereas as principal minor complication 4 partial NAC necrosis not requiring surgery in BNSM (19%) and 2 (9.5%) in NSM. No tissue expanders required explantation. Concerning cosmetic results, the overall appearance of the breast and NAC was acceptable in 85.7 % and 77.2%, respectively, in the NSM group and 80.7% and 66.7%, respectively, in the BNSM group.

CONCLUSIONS

Bipedicled nipple-sparing mastectomy is a valid technique to improve patients' quality of life in large and ptotic breasts otherwise candidate to a skin-sparing mastectomy, but only a progressive learning curve can minimize complications. No significant statistical differences have been observed in terms of complication rates and aesthetical outcomes between the 2 groups. An accurate selection of patients is mandatory in order to obtain low complication rates and good aesthetical outcome.

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.

Optimizing aesthetic outcomes for breast reconstruction in patients with significant macromastia or ptosis

Background

Achieving excellent aesthetic outcomes in reconstruction of large or ptotic breasts is especially challenging. Incorporating a Wise pattern into the mastectomy design is effective in reducing the excess breast skin, however it increases the risk of mastectomy skin necrosis. The aim of this study is to describe surgical maneuvers which optimize aesthetic outcomes, anticipate flap volume requirements, and limit mastectomy skin necrosis in autologous reconstruction in patients with macromastia and grade III ptosis.

Methods

This is a retrospective review of operative and clinical records of patients who underwent unilateral or bilateral breast reconstruction with autologous tissue between August 2015 and May 2017. Patients were divided into macromastia and ptosis groups. Key surgical maneuvers for safely achieving aesthetically optimal results were identified.

Results

A total of 29 breasts were successfully reconstructed in 19 patients with a Wise pattern mastectomy skin reduction. Free flap weights were similar in both groups, mastectomy weights were greater in the macromastia group, p < 0.05. Complications were limited to three cases of wound breakdown and one case of mastectomy skin necrosis. Total number of revision stages was reduced in unilateral reconstructions when a contralateral breast reduction or mastopexy was performed during the first stage.

Conclusions

A Wise pattern can safely and effectively be incorporated into a mastectomy incision design in patients who are not candidates for a nipple sparing mastectomy. Optimal aesthetics are achieved with similar volume flaps for both macromastia and ptosis patients. In cases of unilateral breast reconstruction a contralateral breast reduction or mastopexy should be performed at the time of the immediate breast reconstruction.

Efficacy of double mirrored omega pattern for skin sparing mastectomy to reduce ischemic complications

BACKGROUND

Excellent cosmetic results from skin-sparing mastectomy (SSM) are often impaired by skin flaps' necrosis (SFN), from 8%-25% or worse in smokers. This study prospectively investigated the efficacy of Double-Mirrored Omega Pattern (DMOP-SSM) compared to Wise Pattern SSM (WP-SSM) for immediate reconstruction in moderate/large-breasted smokers.

METHODS

From 2008-2010, DMOP-SSM was performed in 51 consecutive immediate breast reconstructions on 41 smokers (mean age = 49.8 years) with moderate/large and ptotic breasts. This active group (AG) was compared to a similar historical control group (CG) of 37 smokers (mean age = 51.1 years) who underwent WP-SSM and immediate breast reconstruction, with a mean follow-up of 37.6 months. Skin ischaemic complications, number of surgical revisions, time to wound healing, and patient satisfaction were analysed. Descriptive statistics were reported and comparison of performance endpoints was performed using Fisher's exact test and Mann-Whitney U-test. A p-value <.05 was considered significant.

RESULTS

Patients' mean age (p = .316) and BMI (p = .215) were not statistically different between groups. Ischaemic complications occurred in 11.7% of DMOP-SSMs and in 32.4% of WP-SSMs (p = .017), and revision rates were, respectively, 5.8% and 24.3% (p = .012), both statistically significant. Mean time to wound healing was, respectively, 16.8 days and 18.4 days (p = .205). Mean patients' satisfaction scores were, respectively, 18.9 and 21.1, statistically significant (p = .022).

CONCLUSION

Although tobacco use in moderate/large breasted patients can severely impair outcomes of breast reconstruction, the DMOP-SSM approach, compared to WP-SSM, allows smokers to benefit from SSM, but with statistically significant reduced skin flaps ischaemic complications, revision surgery, and better cosmetic outcomes.

Reconstruction of the Ptotic Breast Using Wise Pattern Skin Deepithelialization

Reconstruction of ptotic or large breasts is challenging due to skin redundancy after skin-sparing mastectomy. Skin reduction can be performed with a long horizontal ellipse, but this often flattens the breast and leaves conspicuous scars medially on the chest. Wise pattern skin reduction is an effective technique for shaping, but excision of skin within the Wise pattern can lead to high rates of skin necrosis and implant exposure or infection. This study describes a technique where the Wise pattern skin is preserved, but deepithelialized, allowing apparent reduction of the skin with preservation of the subdermal plexus. This study reviews data for case series of 26 breasts in 15 patients who have undergone this technique with simultaneous prosthetic reconstruction using an expander.

Avoiding Complications in Gigantomastia

Gigantomastia is a disabling condition for patients and presents unique challenges to plastic surgeons. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.

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.

Circumvertical mastectomy incision: refinement in the surgical scar of implant-based breast reconstruction

Different surgical incisions have been proposed for skin-sparing mastectomy in an attempt to better disguise the remaining scar. These techniques are more hidden than the Stewart incision but can still leave scars in visible places and can restrict the natural shape of the upper pole. They can also add complexity and time to the mastectomy, requiring extensive retraction that could damage the salvaged skin flaps to perform an adequate mastectomy. We present a circumvertical mastectomy incision technique, which limits the mastectomy scar to the inferior pole, provides natural lateral contour, superior pole fullness, and contributes to a more youthful breast projection. Between November 2011 and November 2012, 51 women underwent circumvertical AlloDerm/tissue expansion reconstruction at our institution by a single surgeon. The reconstruction was bilateral in 30 patients and unilateral in 21 patients for a total of 81 breasts. Of the 81 reconstructed breasts, 5 patients went on to require a latissimus dorsi flap for definitive reconstruction and 3 failed breast reconstruction for a completion rate of 96%. The goal of creating breast reconstruction results comparable to those of cosmetic breast surgery is becoming a reality. Circumvertical incision is a technique that can prevent visible upper hemispheric breast scarring, limit upper pole constriction by scar placement, and preserves or restores breast projection. Following the principles of aesthetic breast surgery and repositioning the mastectomy scar, one can reconstruct a breast with a more disguised scar, which can be hidden from the patient's downward gaze.

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.

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.

Does post-mastectomy radiotherapy represent a contraindication to skin-sparing mastectomy and immediate reconstruction: an update

The use of skin-sparing mastectomy (SSM) to facilitate breast reconstruction is increasing due to a wide acceptance of improved cosmetic outcomes and evidence of equivalence in oncologic outcomes. The rates of patients undergoing mastectomy for whom post-mastectomy radiotherapy (PMRT) will be recommended is increasing as evidence of decreased loco-regional recurrence and increased survival mounts. PMRT may adversely effect complication rates and cosmetic outcomes for patients undergoing immediate breast reconstruction and PMRT--although the evidence for this is methodologically flawed. This article summarises the above evidence and highlights a reconstructive algorithm that may be used to mitigate the possible deleterious effects of PMRT on results.