Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study

Abstract

Background Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can impact cosmetic outcomes and patient satisfaction, and, in worst cases, potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. Methods We designed a prospective study to capture the rate of skin flap necrosis and pre-, intra-, and post-operative variables with follow-up to 8 weeks post-operatively. Univariate and multivariate analyses were performed for factors associated with skin flap necrosis. Results Out of 606 consecutive procedures, 85 (14%) had some level of skin flap necrosis: 46 (8%) mild, 6 (1%) moderate, 31 (5%) severe, and 2 (0.3%) uncategorized. On univariate analysis for any necrosis, smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal were significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. When looking only at moderate or severe necrosis, BMI, diabetes, nipple-sparing mastectomy, specimen size, and expander size were significant on univariate analysis. Nipple-sparing mastectomy and specimen size were significant on multivariate analysis. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. Conclusions Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.

Nipple-sparing mastectomies: Clinical outcomes from a single academic institution

“…In a prospective study published by Matsen et al (33) examining skin flap necrosis rates following any mastectomy with reconstruction, 14% of patients had some level of skin flap necrosis (33). Using univariate analysis, smoking was revealed to be a significant factor in necrosis rates (32).…”

“…Smoking is established to increase complication rates in breast surgery (5,(31)(32)(33)(34)(35)(36). In a prospective study published by Matsen et al (33) examining skin flap necrosis rates following any mastectomy with reconstruction, 14% of patients had some level of skin flap necrosis (33).…”

Stacked Microsurgical Autologous Flap Breast Reconstruction Is an Ideal Option after Unilateral Nipple-Sparing Mastectomy

“…[1][2][3][4][5][6][7][8][9][10][11][12] Autologous reconstruction in NSM is a safe and effective option that achieves an aesthetic, natural-appearing breast in a single stage. 14,15 However, patients undergoing NSM may be more likely to have a low BMI with a paucity of adequate donor site tissue for reconstruction.…”

“…[1][2][3][4][5][6] Moreover, NSM has been demonstrated in multiple studies to be a safe and effective procedure from a reconstructive perspective, with acceptably low rates of NAC necrosis among other complications. [7][8][9][10][11][12] As the indications for NSM continue to be established, the popularity of this procedure has risen among both patients and surgeons.NSM allows for the complete range of reconstructive procedures, including both prosthetic and autologous options. 13-15 For many patients, NSM with microsurgical autologous reconstruction is an attractive option as it provides for a natural-appearing breast in a single procedure.…”

Systematic review of methodologies used to assess mastectomy flap viability

“…Other factors identified to pose a greater risk of mastectomy flap necrosis include patient‐related factors such as smoking8 9, diabetes mellitus10 11, high BMI10, 11, 12, high mastectomy specimen weight10 11, 13, and previous exposure to radiotherapy12 14. Intraoperative factors such as tumescent mastectomy technique9 15 and Wise‐pattern mastectomy incision13 16 have also been associated with a higher rate of mastectomy flap necrosis17.…”