Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the wise and vertical reduction patterns for mastectomy

Strategies for Prevention and Management of Postoperative Wounds and Scars Following Microsurgical Breast Reconstruction: An Evidence-Based Review

GENERAL PURPOSE

To provide an evidence-based review of strategies for the prevention and management of wounds and postoperative scars following microsurgical autologous breast reconstruction.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Identify operative considerations to promote wound healing in microsurgical autologous breast reconstruction. 2. Synthesize management strategies for major flap complications following microsurgical autologous breast reconstruction. 3. Explain features in the assessment, prevention, and treatment of scars following microsurgical autologous breast reconstruction.

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.

Comparing Wise Pattern to Non-Wise Pattern Skin-Sparing Mastectomy: A Critical Evaluation of Patient Demographics and Surgical Outcomes

BACKGROUND

Multiple skin-sparing incisions are used in immediate postmastectomy breast reconstruction; however, the Wise pattern incision (WPI) may have superior cosmetic outcomes for large, ptotic breasts compared with the non-Wise pattern incision (NWPI). The authors evaluated patient demographics and surgical outcomes with WPI versus NWPI.

METHODS

An electronic medical record search was performed for patients at a single academic institution from 2019 to 2022 with International Classification of Diseases, 10th Revision, Clinical Modification diagnosis code Z42.1: "Encounter for breast reconstruction following mastectomy." Retrospective chart review evaluated patient demographics, intraoperative factors, postoperative complications, and surgical cost.

RESULTS

A total of 288 patients were included: 58 underwent WPI and 230 underwent NWPI. Median body mass index (BMI) differed between WPI (30.5 kg/m 2 ) and NWPI (26.4 kg/m 2 ) ( P < 0.001). Fifty-seven percent of WPI had preoperative grade 3 ptosis versus 23% of NWPI ( P < 0.001). No difference was found in median operative times (WPI, 219 minutes; NWPI, 194 minutes; P = 0.38). Overall rates of postoperative complications differed between WPI (62%) and NWPI (45%) on univariate but not multivariate analysis. Median total surgery charge was higher for WPI (WPI, $36,223; NWPI, $31,185; P < 0.001), whereas implant cost was higher for NWPI (WPI, $2700; NPWI, $8040; P < 0.001).

CONCLUSIONS

There was no significant difference in operative time, overall complication rate, or charge between incision types once adjusted for confounding factors. The higher complication rate in the WPI group was likely driven by higher BMI, a known risk factor for surgical complications regardless of approach. Surgeons can consider WPI as a noninferior option for patients with higher BMI and ptosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Mastectomy Incision Choice in Ptotic Patients Undergoing Immediate Implant-Based Reconstruction: A Comparison of Wise-Pattern and Oblique-Elliptical Incisions

ABSTRACT

Breast ptosis presents challenges for implant-based reconstruction due to the large skin envelope. Skin-reducing mastectomy reduces the envelope but must consider many other factors including complications. Limited data exist on incision impact on outcomes. We compare oblique-elliptical and Wise-pattern incisions on complications and patient-reported quality of life in immediate implant-based reconstruction.A retrospective review of patients who underwent immediate implant-based skin-reducing mastectomy at a single institution from 2015 to 2021 was done and was divided into two cohorts: wise and oblique incisions. Demographics, complications, and patient-reported outcomes (BREAST-Q) were compared. Descriptive, t test, and chi-square test analyses, followed by adjusted linear and logistic regression models, were performed to compare complication rates and BREAST-Q scores.Eighty-nine patient breasts were analyzed, 39 (43.8%) in the oblique (OI) and 50 (56.2%) in the wise (WI) cohort. No differences in demographics or preoperative comorbidities between groups were found. The oblique incision patients had significantly more mean total complications (OI 1.46 vs WI 0.88; P = 0.048), as well as increased incidence of explantation (OI 15 vs WI 3; P = 0.003) and cellulitis (OI 14 vs WI 3; P = 0.020) compared to wise group. Linear regression analysis revealed that incision choice was a significant predictor of complication rate (β = -1.06, 95% CI [-1.63--0.50], P = <0.001). Logistic regression analysis showed that incision was a significant predictor of specific complications such as explantation (odds ratio = 0.10, 95% CI [0.02-0.52], P = 0.006) and cellulitis (odds ratio = 0.16, 95% CI [0.03-0.73], P = 0.018), with decreased risk of choosing wise incision. There was no difference in BREAST-Q results.Ptotic patients with oblique incision are associated with higher rates of postoperative complications compared to wise incisions.These findings suggest that incision choice is an important factor in postoperative complication development and emphasizes the need for further investigation and discussion with patients during preoperative planning.

Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction

BACKGROUND

The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated.

OBJECTIVE

This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective.

METHODS

A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants.

RESULTS

Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study.

CONCLUSIONS

Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.

Immediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates

INTRODUCTION

Elliptical skin-sparing mastectomy in patients with large or ptotic breasts usually leaves loose mastectomy skin flaps, which need to be either resected or gathered over the DIEP flap. This results in poor control of the breast footprint and under-projected DIEP flaps in a loose mastectomy skin pocket, that tend to slip laterally towards the axilla. We believe that the use of a Wise pattern mastectomy will allow for immediate treatment of these concerns.

MATERIALS AND METHODS

A retrospective, uncontrolled analysis of a prospectively-maintained database of patients operated by the five surgeons performing breast reconstructions at the University of Montreal Hospital Centre. Study population was patients with a BMI of over 25 and grade II/III breast ptosis who underwent a Wise pattern mastectomy with immediate DIEP flap reconstruction. Analysis was performed of the complication rates of the technique in the first six months after the surgery.

RESULTS

Out of a total of 53 breasts in 44 patients reconstructed with a DIEP flap immediately post Wise pattern mastectomy, we report nine cases of partial mastectomy-flap necrosis not needing revision, five cases of significant mastectomy flap necrosis needing debridement and skin grafting, and two cases of inability to adequately close the Wise pattern intraoperatively after DIEP placement, necessitating retention of DIEP skin in the inferior pole. None of the mastectomy flap complications occurred in irradiated breasts.

CONCLUSION

In patients with large or ptotic breasts, the Wise pattern mastectomy before an immediate DIEP reconstruction allows for immediate shaping of the breast by controlling the breast pocket, footprint, and excess skin.

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

Iron Reshapes the Gut Microbiome and Host Metabolism

Compelling studies have established that the gut microbiome is a modifier of metabolic health. Changes in the composition of the gut microbiome are influenced by genetics and the environment, including diet. Iron is a potential node of crosstalk between the host-microbe relationship and metabolic disease. Although iron is well characterized as a frequent traveling companion of metabolic disease, the role of iron is underappreciated because the mechanisms of iron's influence on host metabolism are poorly characterized. Both iron deficiency and excessive amounts leading to iron overload can have detrimental effects on cardiometabolic health. Optimal iron homeostasis is critical for regulation of host immunity and metabolism in addition to regulation of commensal and pathogenic enteric bacteria. In this article we review evidence to support the notion that altering composition of the gut microbiome may be an important route via which iron impacts cardiometabolic health. We discuss reshaping of the microbiome by iron, the physiological significance and the potential for therapeutic interventions.

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.

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.

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.

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

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

Analysis of the vertical mammaplasty design in skin-sparing mastectomy and immediate autologous reconstruction

BACKGROUND

Skin-sparing mastectomy designs for immediate autologous breast reconstruction include racquet, Wise, and vertical mammaplasty incisions. The vertical design addresses ptosis while maintaining viable skin flaps. This study compares the racquet to the vertical incision.

METHODS

Immediate skin-sparing autologous breast reconstructions by a single surgeon using either vertical or racquet incisions from August 2006 to September 2011 were analyzed. Aesthetic scoring was based on a Likert-scale assessment of scar appearance, shape, preoperative versus postoperative aesthetic comparison, and overall aesthetic outcome. Responses were analyzed using the Mann-Whitney test.

RESULTS

Seventy-seven patients (48 racquets and 29 vertical) were included. Patient demographics and complications did not differ. Vertical design reconstructions were used for patients with higher-grade ptosis (p < 0.001). Significantly better-appearing scars (3.8 vs. 3.5; p = 0.04) were observed in the vertical group. Vertical reconstructions showed a trend toward significance in cosmetic improvement compared with preoperative appearance (3.2 vs. 3.0; p = 0.06). There was no difference in shape (vertical 3.6, racquet 3.6; p = 0.86) or in postoperative aesthetic result (vertical 3.6, racquet 3.4; p = 0.41).

CONCLUSIONS

Shape and overall postoperative aesthetic appearance did not significantly differ despite greater ptosis preoperatively in the vertical group, demonstrating the efficacy of the vertical design in reconstruction. Vertical design reconstructions were rated aesthetically superior to their pre-mastectomy appearance. Significantly better scar scores in the vertical group reflect the camouflaged nature of vertical incisions. These results demonstrate that the aesthetic outcome of the vertical design reconstruction in ptotic breasts is as good as and potentially superior to the racquet design reconstruction in non-ptotic breasts.

The expanded inframammary fold triangle: Improved results in large volume breast reductions

Context:

The inferior pedicle, Wise-pattern reduction mammaplasty is the most popular technique for breast reduction because of its reproducible results and reliability. However, complication rates in super obese patients or patients receiving large volume reductions are high, ranging from 35 to 78%. These complications include delayed healing, infection, seroma, nipple-areolar complex necrosis, fat necrosis and development of hypertrophic scars.

Aims:

This study aimed to determine whether a modification to the standard Wise-pattern reduction technique, an expanded inframammary fold skin triangle, produces improved outcomes in high-risk large volume breast reduction patients. We report that this modification leads to improved outcomes by decreasing wound complications and improving aesthetic appearance.

Settings and Design:

Twenty-two patients received the inferior pedicle Wise-pattern reduction mammaplasty, which was modified to include an 8 cm wide inferior pedicle. This pedicle was de-epithelialized and an 8 × 3 cm² triangle of skin was preserved at the inferior base to reduce tension at the triple point, inverted T-closure.

Materials and Methods:

A retrospective review was performed on all patients who underwent reduction mammaplasty with the expanded inframammary fold (eIMF) technique as well as all patients who received the standard wise pattern technique.

Statistical Analysis Used:

A student t-test was performed for both reduction populations using SPSS software package. Statistical significance was defined as P < 0.05.

Results:

The average patient age was 32.25 years old (range 18-59), average BMI was 35.0, and average tissue mass removed per breast was 1378.39 g. The modified technique was found to produce a statistically significant (P < 0.05) increase in the amount of breast tissue removed (693.96 g increase in the left and 571.21 g in the right) as well as a statistically significant (P < 0.05) reduction in dehiscence (75% reduction) and post-operative infection (44.10%).

Conclusions:

This method is an easily reproducible and reliable technique that produces a favourable cosmetic outcome with acceptable, sustainable results in high-risk reductions in obese patients.