Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes

Tondu, Thierry; Hubens, Guy; Tjalma, Wiebren A.A.; Thiessen, Filip; Vrints, Ina; Thielen, Jana Van; Verhoeven, Véronique

doi:10.1016/j.bjps.2019.11.047

Cited by 15 publications

(31 citation statements)

References 55 publications

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“…In our study, no necrosis of the NAC or skin envelope was noted following forty-one procedures. The unreliability of the blood supply to the NAC and skin envelope in large breasts is based on several surgery related and non-related factors (10). The length of the skin flap correlates with terminal blood supply in this most remote part of the flap (19,20).…”

Section: Discussionmentioning

confidence: 99%

“…In 2017, Gunnarsson et al (9) used the preshaped principle where the NAC is supplied by a dermoglandular central, superior or superomedial pedicle. Recent review shows tendence of less necrosis in a staged NSM approach (10). In this study we combine preshaping of the breast with NAC delay on an inferior dermoglandular pedicle, together with preshaping of the definite submuscular prosthesis pocket by tissue expansion in two stages.…”

Section: Introductionmentioning

confidence: 99%

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Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

Tondu¹,

Thiessen²,

Hubens³

et al. 2022

Gland Surg

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Background: Large and ptotic breasts are considered an anatomical contraindication for nipple sparing mastectomy (NSM). Necrosis rates can be as high as 76%. The authors examined whether targeted preshaping mastopexy/reduction combined with simultaneous two-stage preshaping of the implant pocket prepares for an uneventful implant reconstruction.Methods: Macromastia and ptosis patients opting for risk-reducing NSM or having a peripherally localized carcinoma in situ, were offered a two-stage mastopexy/reduction simultaneously with preshaping of the implant pocket by subpectoral expansion. Only the inferior pedicle bearing the nipple-areola complex (NAC), remained. A delayed secondary NSM and tissue expander-to-implant reconstruction was scheduled 3 months later. The use of an acellular dermal matrix (ADM) was not necessary because the capsule around the expander created a hammock supporting the definite prosthesis. Follow up was at 2 weeks, 3 months, and 6 months.Results: Forty-one procedures were performed in 24 patients. The mean age was 45±12.08 (range, 22 to 72) years. Patients' mean body mass index (BMI) was 26.79 (range, 19 to 35) kg/m 2 . One patient had diabetes and two smoked. One transient epidermolysis of the NAC occurred in each stage. No NAC or skin necrosis occurred; no implant had to be removed.Conclusions: A two-stage mastopexy/reduction, simultaneously with preshaping of the implant pocket by tissue expansion and followed by a 3-month delayed secondary NSM with tissue expander-to-implant reconstruction is a safe technique in large ptotic breasts.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

Tondu¹,

Thiessen²,

Hubens³

et al. 2022

Gland Surg

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“…The average body mass index of our sample was 24.83kg/m². Davies identified that a high body mass index, breast resections greater than 750g and long distances from NAC to the sternal furcula are factors associated with a higher incidence of skin flap necrosis, [20] while Munhoz identified a high body mass index, breast weight and hemiperiareolar and wise-type incisions as factors associated with higher incidences of complications [21][22][23][24].…”

Section: Discussionmentioning

confidence: 99%

“…Some well-established techniques to skin reduction mastectomy are described in literature. Wise pattern incision and vertical mastopexy incision was widely used in a systematic revision [23]. Folli S, et al shows that wise incision is a good technique for correct large and ptotic breasts using modified McKissock's vertical bi-pedicle dermal flap and helps to maintain the viability of NAC.…”

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confidence: 99%

Systematization of the Incisions in Nipple-Sparing Mastectomy

Mc¹,

Ldp²,

Rcs³

et al. 2021

J Surg Open Access

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Introduction: Nipple-Sparing Mastectomy (NSM) is a consolidated technique that has been used for years with good aesthetic results. Its indication is usually limited by breast size, due to difficulty repositioning the Nipple-Areola Complex (NAC) and treating excess skin in large breasts. The challenge in these cases is to maximize the aesthetic result without increasing the risk of necrosis and other complications.

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“…Since obesity is an increasing phenomenon around the globe [ 1 , 2 ], the number of patients with large and ptotic breasts requiring surgical breast cancer treatment is consistently increasing [ 3 ]. Nipple sparing mastectomies (NSM) and skin sparing mastectomies (SSM) have both proven to be oncologically safe in prophylactic and therapeutic settings after careful oncologic and anatomic selection [ 4 ]. However, in women with large and ptotic breasts, SSM and NSM combined with immediate breast reconstruction (IBR) have higher complication rates than staged approaches [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

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

Vollbach

Thomas

Fansa

2022

JPM

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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

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Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes

Cited by 15 publications

References 55 publications

Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

Systematization of the Incisions in Nipple-Sparing Mastectomy

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

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