Immediate breast reconstruction with a wise pattern mastectomy and NAC-sparing McKissock vertical bipedicle dermal flap

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results

INTRODUCTION

Current breast cancer treatment trends advocate nipple-sparing mastectomy (NSM) as the preferred technique for selected patients. A considerable and ptotic breast is often considered a relative contraindication for NSM due to the increased risk of skin and nipple necrosis.

METHODS

A retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts eligible for NSM for therapeutic or prophylactic purpose. Exclusion criteria comprised a preoperative nipple-sternal notch distance greater than 30 cm, previous radiotherapy, pinch test <1 cm, body mass index (BMI) greater than 34 and active smoke. We present our short-term results with this technique.

RESULTS

During the study period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years [The Interquartile Range (IQR 50.0-68.6)] with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472 g (341-578). Median implant volume was 465 g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients experienced total nipple-areolar complex (NAC) necrosis (3.9%), and partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p = 0.003).

CONCLUSION

If oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

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.

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

Prepectoral Breast Reconstruction in Nipple-Sparing Mastectomy With Immediate Mastopexy

BACKGROUND

Nipple-areola preservation positively impacts quality of life of the patients and helps them to achieve a better psychological and sexual well-being, as well as higher satisfaction with their reconstruction. Patients with large or ptotic breasts, however, represent a technical challenge to surgeons, and nipple-areola preservation may be deferred in this clinical scenario. The aim of this study is to report our experience in patients with large or ptotic breasts who underwent nipple-sparing mastectomy (NSM) and prepectoral implant-based breast reconstruction with immediate mastopexy.

METHODS

A single-institution retrospective chart review was performed in all consecutive patients who underwent NSM and prepectoral implant-based breast reconstruction, simultaneously with mastopexy. This procedure was offered preoperatively to patients who had ptotic or large breasts, which could benefit from mastopexy to obtain a better result. Aesthetic outcomes were evaluated using a modified 5-point Likert scale, and satisfaction and quality of life were evaluated using the reconstruction module of the BREAST-Q questionnaire.

RESULTS

Seventeen NSMs with simultaneous mastopexy were performed on 9 patients. All completed reconstruction successfully, and there were no cases of nipple ischemia or necrosis. Global aesthetic evaluation score was 3.77 (±0.95). The Q-scores were as follows: satisfaction with breast was 90, psychosocial well-being was 95, sexual well-being was 80, and physical well-being with chest was 86.

CONCLUSIONS

In patients with large and/or ptotic breasts, NSM with prepectoral breast reconstruction and immediate mastopexy showed promising results. However, adequate preoperative planning and intraoperative flap assessment are necessary in order to minimize complications.

Skin-Reducing Mastectomy with Immediate Prepectoral Reconstruction: Surgical, Aesthetic, and Patient-Reported Outcomes with and without Dermal Matrices

BACKGROUND

Prepectoral breast reconstruction is being increasingly popularized, largely because of technical advances. Patients with ptotic breasts and active cancer require mastectomies through a mastopexy excision pattern to achieve proper pocket control in a prepectoral single-stage operation. This article presents a single-surgeon experience with direct-to-implant, prepectoral reconstruction following skin-reducing mastectomies.

METHODS

A retrospective chart review identified all patients undergoing prepectoral, direct-to-implant breast reconstruction following Wise-pattern mastopexy from June of 2016 to June of 2018. Surgical and aesthetic outcomes, including capsular contracture and revision surgery, were measured. The BREAST-Q was administered preoperatively, 6 months postoperatively, and 1 year postoperatively.

RESULTS

Eighty-four patients (121 breasts) were included. A widely based inframammary fold adipodermal flap was used in all cases, with acellular dermal matrix used in 77 breasts (63.3 percent), free nipple grafts in 42 breasts (34.7 percent), and postmastectomy radiation therapy in 31 breasts (26.5 percent). Operative complications included nipple-areola complex necrosis in six (5.1 percent), hematoma in four (3.4 percent), seroma in four (3.4 percent), implant exposure in three (2.6 percent), and infection in one (0.9 percent). Minor complications included cellulitis in five (6.0 percent) and minor wound issues in five (4.3 percent). In aesthetic outcomes, only two nonirradiated breasts experienced a grade 3 to 4 or grade 4 capsular contracture requiring capsulectomy. Rippling was visible in four breasts (3.4 percent). The BREAST-Q showed good satisfaction with the technique, with no significant differences between nipple-areola complex techniques.

CONCLUSIONS

This cohort represents the largest single-surgeon, Wise-pattern, direct-to-implant prepectoral database in the literature. This report showed that surgical and aesthetic complications did not differ in terms of acellular dermal matrix use. This technique has shown, through patient-reported outcomes, to yield good patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Benefits and Pitfalls of Using an Autologous Dermal Flap in Immediate Implant-Based Reconstruction

One of the challenges of implant breast reconstruction post-subcutaneous mastectomy is coverage of the inferior pole of the implant to provide a barrier between the implant and skin. Numerous biological and synthetic meshes are available on the market for this purpose; however, they are often very costly and carry all the risks of using a foreign body. In patients with large ptotic breast, the skin of the inferior mastectomy flap can be used instead. A number of techniques and variations have been developed over the last 40 years driven by the increasing cost of healthcare and acceptance of breast reconstruction as vital part of breast cancer care and survivorship. This review outline the benefits and pitfalls of using an autologous dermal flap in breast construction and the variations in published use.

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 ⊕).