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

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.

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.

One-Stage Immediate Alloplastic Breast Reconstruction in Large and Ptotic Breasts: An Institutional Algorithm

Immediate implant-based breast reconstruction in patients with large and ptotic breasts may be challenging due to skin redundancy. The use of a reduction mammoplasty pattern for the mastectomy skin excision has proven to be a reliable option for these patients as it allows for a better shape, projection, and symmetrization. This approach has been described in the literature for both one- and two-stage reconstruction with either sub- or pre-pectoral reconstruction with an acellular dermal matrix (ADM) or non-biological mesh. One-stage immediate breast reconstructions have a positive significant impact on patients' psychosocial well-being and quality of life. The purpose of this paper is to describe an institutional algorithm that allows one to perform one-stage implant-based breast reconstructions in patients with large and ptotic breasts.

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.

Inverted-T pattern reduction mammoplasty in bilateral breast ptosis: cosmetic and oncological outcomes

Background

Breast ptosis is directly caused by Cooper's ligament laxity, with the decline of nipple areola complex (NAC) and mammary parenchyma. Breast cancer with ptosis is always a knotty problem that can hardly be repaired by classic breast conservation surgery (BCS) ending up with a pleasing appearance. We analyzed our 12 years' experience of performing inverted-T pattern techniques to treat bilateral breast ptosis, with or without breast cancer.

Methods

One hundred forty-eight breasts in 74 patients undergoing inverted-T pattern reduction mammoplasty were included in this study. Information about patients' clinical and surgical characteristics, complications, NAC sensitivity, cosmetic and oncological outcomes were collected and retrospectively analyzed.

Results

In the cohort of 57 patients with pure breast ptosis, the mean body mass index (BMI) was 25.2 kg/m², and the mean weight of resected tissue from the left and right breast reductions were 744.9 and 756.7 g. In the cohort of 17 patients diagnosed as breast cancer with ptosis, the mean BMI was 25.1 kg/m², and the mean weight of resected tissue were 504.1 g for left and 535.6 g for right side. The majority of repairs were performed for tumors located in the upper outer (58.8%), mostly with inferior or superomedial pedicles (90%). All the upper inner tumors were repaired with inferior pedicles. Minor complications such as seroma (8.1%), NAC epidermolysis (8.1%), delayed wound healing (4.1%) were detected postoperatively. Partial NAC necrosis occurred in one patient (1.4%). 82.4% of all the patients rated "very satisfied" or "satisfied" as the final cosmetic outcomes. NAC sensitivity was "very high" and "high" in 82.4% patients. No local occurrence, distant metastasis and mortality occurred in tumor patients.

Conclusions

The inverted-T pattern reduction mammoplasty is a reliable technique to treat bilateral breast ptosis with a low complication rate. For cases with breast cancer, this technique can achieve both satisfying cosmetic outcomes and oncological safety.

Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

Background:

This study sets out to compare reconstructive practice between patients undergoing immediate breast reconstruction (IBR) for cancer and those who opted for risk reduction (RR), with an emphasis on examining patterns of secondary surgery.

Methods:

Data collection was performed for patients undergoing mastectomy and IBR at a teaching hospital breast unit (2013–2016).

Results:

In total, 299 patients underwent IBR (76% cancer versus 24% RR). Implant-based IBR rate was similar in both groups (58% cancer versus 63% RR). Reconstruction loss (5.3% cancer versus 4.2% RR) and complication (16% cancer versus 12.9% RR) rates were similar. Cancer patients were more likely to undergo secondary surgery (68.4% versus 56.3%; P = 0.025), including contralateral symmetrization (22.8% versus 0%) and conversion to autologous reconstruction (5.7% versus 1.4%). Secondary surgeries were mostly planned for cancer patients (72% planned versus 28% unplanned), with rates unaffected by adjuvant therapies. This distribution was different in RR patients (51.3% planned versus 48.7% unplanned). The commonest secondary procedure was lipomodeling (19.7% cancer versus 23.9% RR). For cancer patients, complications resulted in a significantly higher unplanned secondary surgery rate (82.5% versus 38.8%; P = 0.001) than patients without complications. This was not evident in the RR patients, where complications did not lead to a significantly higher unplanned surgery rate (58.9% versus 35.2%; P = 0.086).

Conclusions:

Most of the secondary surgeries were planned for cancer patients. However, complications led to a significantly higher rate of unplanned secondary surgery. Approximately 1 in 4 RR patients received unplanned secondary surgery, which may be driven by the desire to achieve an optimal aesthetic outcome.