Autologous reconstruction following nipple sparing mastectomy: a comprehensive review of the current literature

Abstract

As surgical methods continue to evolve and patients become more educated consumers of their medical care, both oncologic breast surgeons and reconstructive plastic surgeons should understand the current options for surgical management of breast cancer. This review evaluates the current autologous breast reconstruction options following nipple sparing mastectomy (NSM). A comprehensive review of the current literature discussing autologous reconstruction after NSM was performed. Fat grafting alone has been used to reconstruct small to medium sized-breasts over multiple injection sessions. Goldilocks mastectomy-like reconstructions can be used for larger, more ptotic breasts. Pedicled latissimus dorsi (LD) flaps can be used, but usually need to be modified to ensure sufficient breast volume. While the lower abdominal tissue remains the most common donor site in free tissue transfer, other donor sites can be used if there is insufficient volume or inadequate perforators. Periareolar incisions are associated with the highest rates of overall complications and nipple areola complex necrosis. It has not been determined whether implant-based or autologous reconstructions have lower complication rates. Both prior radiation and large, ptotic breasts present unique challenges during reconstruction. Overall, there is a high rate of patient satisfaction with breast reconstruction following NSM. Autologous breast reconstruction after NSM is a safe method of breast cancer surgical management with aesthetically excellent results. Multiple techniques have been described along the reconstructive ladder. Special consideration should be given to choices of incision, previously irradiated breasts, and large, ptotic breasts.

Thoracoacromial artery and vein as main recipient vessels in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction

“…Advantages of the use of the TAA/V as recipient vessels for free DIEP flap breast reconstruction include less invasiveness, preservation of the IMA for possible future CABG, preservation of the TDA/V for a salvage option of breast reconstruction using a LDMC flap, and its anatomical familiarity to reconstructive microsurgeons 2‐4,12,23,24 . As demonstrated in this study results, postoperative pain score and acetaminophen usage were significantly lower in TAA/V group than IMA/V group.…”

“…Breast reconstruction is an important procedure for improvement of quality of life of patients with breast cancer undergoing total mastectomy 1‐5 . Unlike silicone breast implant, autologous tissue reconstruction provides more natural‐textured breast without long‐term complications such as breast implant contracture and malignant lymphoma development 1,4‐6 .…”

“…Unlike silicone breast implant, autologous tissue reconstruction provides more natural‐textured breast without long‐term complications such as breast implant contracture and malignant lymphoma development 1,4‐6 . Among various autologous breast reconstruction, lower abdominal flaps including deep inferior epigastric artery (DIEA) perforator (DIEP) flap are the most popular with reproducible pleasing results 2,3,7 . A DIEP flap has a long pedicle and sufficient volume, allowing optimal insetting of the flap for breast reconstruction 4,7‐9 .…”

“…The LTA/V and TDA/V branches can be too small as recipient vessels, and are more distant than the IMA/V 4,8‐10 . The use of the TDA/V limits an option of latissimus dorsi myocutaneous (LDMC) flap for salvage breast reconstruction 2,5,7,14 …”

Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987–2020)

“…In recent years, with the increasing appreciation of patient reported outcome measures in women undergoing risk reducing surgery [ 89 ], surgeons have sought more aesthetically focussed reconstruction options whilst not compromising risk-reduction principles. This has allowed the safe introduction of skin sparing and nipple sparing mastectomy [ 90 ] and autologous reconstruction with deep inferior epigastric perforator flaps [ 91 ] or single-stage prepectoral implant-based reconstruction [ 92 ]. The use of acellular dermal matrices has revolutionised implant-based reconstruction, allowing structural support of implants within a reconstruction to mimic natural breast ptosis [ 93 ].…”