Risk Factors for Skin Flap Necrosis in Breast Cancer Patients Treated with Mastectomy Followed by Immediate Breast Reconstruction

Implants versus autologous tissue flaps for breast reconstruction following mastectomy

BACKGROUND

Women who have a mastectomy for breast cancer treatment or risk reduction may be offered different options for breast reconstruction, including use of implants or the woman's own tissue (autologous tissue flaps). The choice of technique depends on factors such as the woman's preferences, breast characteristics, preoperative imaging, comorbidities, smoking habits, prior chest or breast irradiation, and planned adjuvant therapies.

OBJECTIVES

To assess the effects of implants versus autologous tissue flaps for postmastectomy breast reconstruction on women's quality of life, satisfaction, and short- and long-term surgical complications.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registries in July 2022.

SELECTION CRITERIA

We included studies that compared implant-based reconstruction with autologous tissue-based reconstruction following mastectomy for breast cancer treatment or risk reduction. The minimum eligible sample size was 100 participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data using standard Cochrane procedures. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

Thirty-five non-randomised studies with 57,555 participants met our inclusion criteria. There were nine prospective cohort studies and 26 retrospective cohort studies. We judged 26 studies at serious overall risk of bias and the remaining studies at moderate overall risk of bias. Some studies measured quality of life and satisfaction using the BREAST-Q (scale of 0 to 100, higher is better). Implants may reduce postoperative psychosocial well-being compared with autologous tissue flaps (mean difference (MD) -4.26 points, 95% confidence interval (CI) -4.91 to -3.61; I² = 0%; 6 studies, 3335 participants; low-certainty evidence). Implants may reduce or have little to no effect on postoperative physical well-being compared with autologous tissue flaps, but the evidence is very uncertain (MD -1.92 points, 95% CI -4.44 to 0.60; I² = 87%; 6 studies, 3335 participants; very low-certainty evidence). Implants may reduce postoperative sexual well-being compared with autologous reconstruction (MD -6.63 points, 95% CI -7.55 to -5.72; I² = 0; 6 studies, 3335 participants; low-certainty evidence). Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the breast, but the evidence is very uncertain (MD -8.17 points, 95% CI -11.41 to -4.92; I² = 90%; 6 studies, 3335 participants; very low-certainty evidence). This outcome refers to a woman's satisfaction with breast size, bra fit, appearance in the mirror (clothed or unclothed), and how the breast feels to touch. Women who undergo breast reconstruction with implants versus autologous tissue flaps may be less satisfied with the reconstruction (MD -5.96 points, 95% CI -10.24 to -1.68; I² = 62%; 4 studies, 1196 participants; low-certainty evidence). This outcome refers to whether the aesthetic outcome has met the woman's expectations, the impact surgery has had on her life, and whether she thinks she made the right decision to have the reconstruction. Implants may reduce or have little to no effect on the risk of short-term complications compared with autologous tissue flaps, but the evidence is very uncertain (risk ratio (RR) 0.80, 95% CI 0.63 to 1.03; I² = 91%; 22 studies, 34,244 participants; very low-certainty evidence). Implants may increase long-term complications compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.56, 95% CI 1.09 to 2.22; I² = 94%; 17 studies, 26,930 participants; very low-certainty evidence). Implants may have little to no effect on the need for reintervention compared with autologous tissue flaps, but the evidence is very uncertain (RR 1.23, 95% CI 0.91 to 1.68; I² = 93%; 15 studies, 14,171 participants; very low-certainty evidence). Implants may reduce the duration of surgery compared with autologous tissue flaps, but the evidence is very uncertain (MD -125.04 minutes, 95% CI -131.41 to -118.67; I² = 0; 2 studies, 836 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The findings of this review show that autologous tissue-based reconstruction compared with implant-based reconstruction may improve participant-reported outcomes such as psychosocial well-being, sexual well-being, and satisfaction with the reconstruction. There is also very uncertain evidence to suggest that autologous tissue-based reconstruction increases satisfaction with the breast and reduces the risk of long-term complications compared with implants. Implant-based reconstruction may be a shorter procedure, but the evidence is very uncertain. Despite the growing demand for breast reconstruction, the best technique has not been adequately studied in randomised controlled trials (RCTs), and the evidence provided by non-randomised studies is often unsatisfactory. There is no superior breast reconstruction technique for all women. Future research should focus on the definition of decisional drivers to guide an evidence-based shared decision-making process in reconstructive breast surgery.

Comparative complications of prepectoral versus subpectoral breast reconstruction in patients with breast cancer: a meta-analysis

Introduction

This meta-analysis aims to evaluate the complications associated with prepectoral breast reconstruction (PBR) compared to subpectoral breast reconstruction (SBR) in patients diagnosed with breast cancer.

Materials and methods

A comprehensive search was performed in four databases, including Medline, Embase, Web of Science and CENTRAL, to collect literature published up until December 31, 2024. In addition, we conducted a thorough manual examination of the bibliographies of the identified papers, as well as pertinent reviews and meta-analyses. We conducted a search on three clinical trial registries, namely ClinicalTrials.gov, Controlled-trials.com, and Umin.ac.jp/ctr/index.htm. Meta-analyses were conducted on total complications, hematoma, infection, wound healing issues, necrosis, capsular contracture, rippling, animation deformity, and reoperation.

Results

A total of 40 studies were included in the meta-analysis. Compared with SBR, PBR significantly reduced the incidence of animated malformations (OR=0.37, 95% CI: 0.19 to 0.70, P=0.003, I ²=12%), but increased the incidence of ripples (OR=2.39, 95% CI: 1.53 to 3.72, P=0.0001, I ²=10%) and seroma (OR=1.55, 95% CI: 1.02 to 2.35, P=0.04, increasing I ²=70%).

Conclusions

Our findings indicate that PBR and SBR have comparable safety profiles, with similar total complication rates. Specifically, PBR is more likely to cause rippling and seroma, whereas SBR is more prone to causing animation deformity.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024565837, identifier CRD42024565837.

Updated findings of skin flap thickness and residual breast tissue after mastectomy for breast cancer: a systematic review of the literature

BACKGROUND

There is limited evidence on the ideal retention thickness of skin flap in mastectomy. Residual breast tissue (RBT) after mastectomy still represents an unknown risk for local recurrence or new breast cancer lesions. We made this systematic review to identify the optimal flap after mastectomy with minimal complications and better oncological safety.

METHODS

A systematic review was performed using MEDLINE search in PubMed, Embase, and Cochrane Library with the search terms relevant to skin flap thickness and residual breast tissue in breast cancer patients undergoing mastectomy.

RESULTS

Twenty-one studies were included of which fifteen studies enrolled 3814 patients who received mastectomy, and additional six studies were based on cadavers or breast specimens. Four studies confirmed the presence of the superficial fascial layer (Camper's fascia) which can theoretically be used as an anatomical marker for flap retention during mastectomy. Two other studies confirmed Camper's fascia deficiency to a greater or lesser extent. The flap thickness ranged from 3.8 mm to 23 mm in 2692 patients of 7 studies, which was related to BMI, breast size, and examination modalities. Two retrospective and one prospective studies confirmed flaps exceeding 5 mm could significantly increase postoperative complications. Nine studies including 1122 patients explored the association among flap thickness, RBT, and complications, 3 studies of which confirmed excessive flap thickness could cause a significant increase in RBT, which proved to be a potential risk factor for local recurrence in 3 studies. Flaps beyond 5 mm were also found to significantly increase the chance of local recurrence in 4 studies.

CONCLUSION

Camper's fascia can serve as an ideal demarcation between fat and breast tissue based on most current studies. 5 mm thickness of the flap retention in mastectomy is recommended if Camper's fascia is absent or obscure, through which better cosmetic outcomes and less RBT can be achieved.

Impact of mastectomy flap necrosis on prepectoral reconstructive outcomes

INTRODUCTION

As reconstructive surgeons have increasingly transitioned to the prepectoral plane for prosthetic breast reconstruction, the implications of mastectomy skin flap necrosis have become more concerning. Our goal was to evaluate the effect of skin flap necrosis on reconstructive outcomes in patients undergoing immediate prepectoral breast reconstruction.

METHODS

A retrospective review was conducted of patients undergoing immediate two-stage prepectoral reconstruction at a single center with at least 3 months follow-up. Postoperative complications, reconstructive outcome, and time to final implant were compared between patients with and without mastectomy skin necrosis.

RESULTS

A total of 301 patients underwent 509 prepectoral breast reconstructions. Forty-four patients (14.6%) experienced postoperative mastectomy skin flap necrosis. Demographic and reconstructive characteristics were similar between the necrosis and no necrosis cohorts. Patients with skin necrosis were more likely to undergo reoperation after tissue expander (64% vs 19%, p < 0.01) and undergo expander replacement (13.6% vs 3.5%, p = 0.02). However, rates of reconstructive failure (6.8% vs 6.2%), major infection (9.1% vs 9.0%), and minor infection (13.6% vs 17.5%) after expander placement were statistically similar. Patients with skin necrosis trended toward longer time before final implant placement, although the difference was not statistically significant (6.5 vs 5.0 months, p = 0.08). There was no difference in complication rates between the necrosis and no necrosis cohort after final implant placement. There was a higher rate of revision surgery after implant placement in the necrosis cohort (12.5% vs 4.1%, p = 0.047).

CONCLUSIONS

Mastectomy skin flap necrosis is a concerning postoperative event, particularly in patients with prepectoral prostheses. We observed that patients with skin necrosis experience higher reoperation rates in the expander period, yet have similar infection rates and achieve similar final reconstructive outcomes compared to patients without necrosis.

Air or Saline? A Propensity Score-Matched Analysis on the Effect of Tissue Expander Fill on Complications in Immediate Breast Reconstruction

BACKGROUND

Tissue expander fill medium and volume have implications for the pressure exerted on mastectomy skin flaps. This study evaluated the influence of initial fill medium (air vs. saline) on complications in immediate breast reconstruction within a propensity score-matched cohort.

PATIENTS AND METHODS

Patients undergoing immediate tissue expander-based breast reconstruction with initial intraoperative fill with air were propensity score matched 1:2 to those with saline initial fill based on patient and tissue expander characteristics. Incidence of overall and ischemic complications were compared by fill medium (air vs. saline).

RESULTS

A total of 584 patients were included, including 130 (22.2%) with initial fill with air, 377 (64.6%) with initial fill with saline, and 77 (13.2%) with 0 cc of initial fill. After multivariate adjustment, higher intraoperative fill volume was associated with increased risk of mastectomy skin flap necrosis [regression coefficient (RC) 15.7; p = 0.049]. Propensity score matching was then conducted among 360 patients (Air: 120 patients vs. Saline: 240 patients). After propensity score matching, there were no significant differences in the incidences of mastectomy skin flap necrosis, extrusion, reoperation, or readmission between the air and saline cohorts (all p > 0.05). However, initial fill with air was associated with lower incidence of infection requiring oral antibiotics (p = 0.003), seroma (p = 0.004), and nipple necrosis (p = 0.03).

CONCLUSIONS

Within a propensity score-matched cohort, initial fill with air was associated with a lower incidence of complications, including ischemic complications after nipple-sparing mastectomy. Initial fill with air and lower fill volumes may be strategies to reducing risk of ischemic complications among high-risk patients.

Development and Assessment of Machine Learning Models for Individualized Risk Assessment of Mastectomy Skin Flap Necrosis

OBJECTIVE

To develop, validate, and evaluate ML algorithms for predicting MSFN.

BACKGROUND

MSFN is a devastating complication that causes significant distress to patients and physicians by prolonging recovery time, compromising surgical outcomes, and delaying adjuvant therapy.

METHODS

We conducted comprehensive review of all consecutive patients who underwent mastectomy and immediate implant-based reconstruction from January 2018 to December 2019. Nine supervised ML algorithms were developed to predict MSFN. Patient data were partitioned into training (80%) and testing (20%) sets.

RESULTS

We identified 694 mastectomies with immediate implant-based reconstruction in 481 patients. The patients had a mean age of 50 ± 11.5 years, years, a mean body mass index of 26.7 ± 4.8 kg/m 2 , and a median follow-up time of 16.1 (range, 11.9-23.2) months. MSFN developed in 6% (n = 40) of patients. The random forest model demonstrated the best discriminatory performance (area under curve, 0.70), achieved a mean accuracy of 89% (95% confidence interval, 83-94), and identified 10 predictors of MSFN. Decision curve analysis demonstrated that ML models have a superior net benefit regardless of the probability threshold. Higher body mass index, older age, hypertension, subpectoral device placement, nipple-sparing mastectomy, axillary nodal dissection, and no acellular dermal matrix use were all independently associated with a higher risk of MSFN.

CONCLUSIONS

ML algorithms trained on readily available perioperative clinical data can accurately predict the occurrence of MSFN and aid in individualized patient counseling, preoperative optimization, and surgical planning to reduce the risk of this devastating complication.

Using Clinical Measurements to Predict Breast Skin Necrosis: A Quantitative Analysis

BACKGROUND

Breast skin necrosis can lead to poor healing, reoperation, and unaesthetic reconstructive outcomes after mastectomy. Furthermore, the prolonged recovery can delay adjuvant oncologic regimens. This study aims to explore the role of breast surface area as a risk factor for mastectomy skin flap necrosis and to identify predictive clinical measurements.

METHODS

The authors retrospectively identified patients who underwent immediate breast reconstruction (N = 926 breasts) by 2 surgeons at a single institution between 2011 and 2021. Preoperative breast measurements such as nipple-notch (NN) distance, nipple-inframammary fold (NF) distance, chest width (CW), breast circumference (BC), and breast height (BH) were used to estimate breast surface area. Univariate analysis and receiver operating characteristic curves were used to determine predictive measurements and optimal cutoff values.

RESULTS

When approximated using either a cone without base or a half ellipsoid, larger surface area was a significant risk factor for mastectomy skin flap necrosis (P = 0.027 and P = 0.022, respectively). Larger NN, NF, CW, BC, and BH measurements were significant predictors of necrosis (P < 0.05). Surface area (cone without base) greater than 212 cm2, surface area (half ellipsoid) greater than 308 cm2, NN distance greater than 27 cm, NF greater than 8.5 cm, CW greater than 15 cm, BC greater than 29 cm, and BH greater than 10.5 cm are all values shown to increase the incidence of necrosis.

CONCLUSIONS

Larger breast surface area is an independent risk factor for breast skin necrosis. Preoperative breast measurements can be a useful adjunct for predicting necrosis in postmastectomy patients.

Prepectoral Versus Subpectoral Implant-Based Breast Reconstruction: A Systemic Review and Meta-analysis

BACKGROUND

Implant-based breast reconstruction (IBBR) remains the standard and most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral IBBR has resurged in popularity, despite limited data comparing prepectoral with subpectoral IBBR.

METHODS

A systematic search of PubMed and Cochrane Library from January 1, 2011 to December 31, 2021, was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines, data were extracted by independent reviewers. Studies that compared prepectoral with subpectoral IBBR for breast cancer were included.

RESULTS

Overall, 15 studies with 3,101 patients were included in this meta-analysis. Our results showed that patients receiving prepectoral IBBR experienced fewer capsular contractures (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.32-0.92; P = 0.02), animation deformity (OR, 0.02; 95% CI, 0.00-0.25; P = 0.002), and prosthesis failure (OR, 0.58; 95% CI, 0.42-0.80; P = 0.001). There was no significant difference between prepectoral and subpectoral IBBR in overall complications (OR, 0.83; 95% CI, 0.64-1.09; P = 0.19), seroma (OR, 1.21; 95% CI, 0.59-2.51; P = 0.60), hematoma (OR, 0.76; 95% CI, 0.49-1.18; P = 0.22), infection (OR, 0.87; 95% CI, 0.63-1.20; P = 0.39), skin flap necrosis (OR, 0.70; 95% CI, 0.45-1.08; P = 0.11), and recurrence (OR, 1.31; 95% CI, 0.52-3.39; P = 0.55). Similarly, no significant difference was found in Breast-Q scores between the prepectoral and subpectoral IBBR groups.

CONCLUSIONS

The results of our systematic review and meta-analysis demonstrated that prepectoral, implant-based, breast reconstruction is a safe modality and has similar outcomes with significantly lower rates of capsular contracture, prosthesis failure, and animation deformity compared with subpectoral, implant-based, breast reconstruction.

Prospective Evaluation of Complications and Associated Risk Factors in Breast Cancer Surgery

Background

Surgical site infection (SSI) is a well-known complication after breast cancer surgery. The primary aim was to assess risk factors for SSI. Risk factors for other wound complications were also studied.

Materials and Methods

In this prospectively registered cohort study, patients who underwent breast-conserving surgery (BCS) or mastectomy between May 2017 and May 2019 were included. Data included patient and treatment characteristics, infection, and wound complication rates. Risk factors for SSI and wound complications were analyzed with simple and multiple logistic regression.

Results

The study cohort consisted of 592 patients who underwent 707 procedures. There were 66 (9.3%) SSI and 95 (13.4%) wound complications. "BMI > 25," "oncoplastic BCS," "reoperation within 24 hour," and "prolonged operative time" were risk factors for SSI with simple analysis. BMI 25-30 and >30 remained as significant risk factors for SSI with adjusted analysis. Risk factors for "any wound complication" with adjusted analysis were "mastectomy with/without reconstruction" in addition to "BMI 25-30" and "BMI > 30."

Conclusion

The only significant risk factor for SSI on multivariable analysis were BMI 25-30 and BMI > 30. Significant risk factors for "any wound complication" on multivariable analysis were "mastectomy with/without reconstruction" as well as "BMI 25-30" and "BMI > 30".

The Impact of Preoperative Breast Volume on Development of Mastectomy Skin Flap Necrosis in Immediate Breast Reconstruction

BACKGROUND

Mastectomy skin flap necrosis (MSFN) can significantly impact outcome after immediate breast reconstruction. Several techniques exist to predict MSFN, but these may require additional testing and information, and they are often not available before surgery. We aim to identify whether breast volume, as calculated from preoperative mammography, can be used as a preoperative predictor of MSFN.

METHODS

A retrospective chart review from 2010 to 2020 resulted in 378 patients who underwent immediate implant-based breast reconstruction. Complete imaging data were available for 278 patients and 441 reconstructed breasts. Demographic, perioperative, and outcomes data were collected. Measurements from preoperative diagnostic mammograms were used to calculate breast volume. Univariate and multivariate analyses were used to evaluate the association of variables available preoperatively, including breast volume from mammogram and MSFN. Secondary analyses were performed for need for reoperation and loss of reconstruction.

RESULTS

On univariate analysis of MSFN development, demographic variables found to be significantly associated with MSFN included body mass index (P = 0.04), diabetes (P = 0.03), and breast volume calculated from routine mammography (P ≤ 0.0001). Average preoperative breast volume via mammography without and with MSFN was 970.6 mL (95% confidence interval [CI], 908.9-1032.3) and 1298.3 mL (95% CI, 1140.0-1456.5) (P < 0.0001), respectively. Statistically significant intraoperative variables for MSFN development included prolonged operative time (P = 0.005), greater initial tissue expander fill volumes (P ≤ 0.001), and prepectoral implant location (P = 0.02). Higher initial tissue expander fill volumes in implant-based reconstructions were associated with increased rates of MSFN, 264.1 mL (95% CI, 247.2-281.0) without MSFN and 349.9 mL (95% CI, 302.0-397.8) in the group with MSFN, respectively (P < 0.001). On multivariate analysis, preoperative imaging volume (P = 0.02) was found to be significant, whereas body mass index and diabetes lost significance (P = 0.40) in association with MSFN.

CONCLUSIONS

The results of this study establish an association between larger breast volume on preoperative imaging and development of MSFN. This may be useful as a tool for more appropriate patient selection and guidance in the setting of immediate breast reconstruction.

Utility of indocyanine green angiography in delaying breast reconstruction postmastectomy

Background

Perfusion mapping with indocyanine green angiography (ICGA) in breast reconstruction can change intraoperative plans and reduce the risk of flap necrosis. We evaluated the utility of ICGA in the decision to delay reconstruction postmastectomy and its predictive power for necrosis.

Methods

Single-institution retrospective study of implant-based breast reconstructions following mastectomy using ICGA from 2015 to 2021. A decision was made to proceed with immediate reconstruction or delay reconstruction based on clinical assessment and perfusion analysis. Incidence of complications in the immediate and delayed cohorts were assessed. Intraoperative ICGA perfusion values were correlated with postoperative outcomes to calculate diagnostic accuracy.

Results

Three hundred twenty breast reconstructions were performed. Two hundred fifty-nine of these underwent immediate reconstruction, while 61 underwent delayed reconstruction due to poor perfusion. Median time between mastectomy and delayed reconstruction was 7.3 days (range, 4–21 days). All 8 cases (3.1%) of necrosis were in the immediate cohort. Cases of necrosis had significantly lower intraoperative ICGA perfusion values compared to cases without necrosis (absolute values 13.1 versus 27.1 units, p = 0.017). Increasing our ICGA cut-off score for necrosis from 14 to 22 units would have increased sensitivity from 63 to 100% but reduced specificity from 70 to 48%.

Conclusions

Delayed breast reconstruction due to poor perfusion on ICGA resulted in no cases of necrosis. A higher ICGA cut-off score for predicting necrosis is more sensitive but less specific. ICGA is useful as a supplement rather than a substitute for clinical assessment in flap perfusion evaluation.

Level of Evidence Level III, Risk / Diagnostic Study.

Pre-pectoral breast reconstruction: early and long-term safety evaluation of 146 unselected cases of the early pre-pectoral era of a single-institution, including cases with previous breast irradiation and post-mastectomy radiation therapy

We re-evaluated acute and early-late toxicity-related factors among pre-pectoral immediate tissue expander/implant (TE/I) breast reconstruction (BR) unselected, first-era, cases, including previous breast radiation treatment and post-mastectomy radiation therapy (PMRT). A retrospective analysis of 146 (117 therapeutic and 29 prophylactic) pre-pectoral reconstructions, between 2012 and 2016, considered patient-related (age, body mass index [BMI], smoke-history, comorbidity, BRCA mutation), and treatment-related characteristics (previous irradiation, axillary surgery, PMRT, pre- and postoperative chemotherapy, endocrine therapy, and target-therapy). Safety was evaluated as acute and early-late complications, and TE/I failures. At multivariate analysis of the 146 cases (117 patients submitted to BR) a significant factor related to acute toxicity was: BMI ≥ 25 (31.3% [≥ 25] vs 8.8% [< 25]; OR 4.44, 95% CI 1.56-12.6; p = 0.003), while previous breast surgery on ipsilateral side presented a borderline significance (31.6% [previous surgery] vs 7.4% [no previous surgery]; OR 3.74, 95% CI 0.97-14.40; p = 0.055). Factors significantly related to TE/I failure were: current or previous smoking exposition (13.8% [smokers] vs 2.6% [non-smokers]; OR 7.32, 95% CI 1.37-39.08; p = 0.02) and preoperative chemotherapy (18.8% [yes] vs 3.5% [no]; OR 8.16, 95% CI 1.29-51.63; p = 0.026). At 4-year median follow-up, 3 deaths, 5 locoregional recurrences, and 14 distant metastases occurred. Immediate pre-pectoral BR is safe and effective, with low rates of acute and early-late complications. BMI and previous breast surgery were related to higher complications but not failure; smoking and preoperative chemotherapy were related to TE/I explant. Previous RT and PMRT were related neither to early-late toxicity nor failure.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery

BACKGROUND

Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS.

MATERIALS AND METHODS

Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss.

RESULTS

956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567).

CONCLUSION

In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss

BACKGROUND

Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM.

METHODS

Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses.

RESULTS

From 2015 to 2019, 109 breasts underwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place 20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75).

CONCLUSIONS

Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

Prepectoral immediate breast reconstruction with polyurethane foam-coated implants: Feasibility and early results in risk-reducing and therapeutic mastectomies

BACKGROUND

There is a renewed interest for prepectoral reconstruction. We aimed to describe the feasibility and the early complications associated with immediate one-stage direct-to-implant (DTI) reconstruction using prepectoral anatomical polyurethane (PU) foam-coated implants alone, for women with breast cancer or mutation carriers undergoing risk-reducing surgery.

METHODS

We performed a single-center, retrospective review of 50 patients (mean age of 49 years), who underwent skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) and immediate prepectoral PU implant-based reconstruction. All procedures were performed by the same senior operator, from July 2018 to March 2020.

RESULTS

A total of 64 mastectomies (25 SSMs and 39 NSMs) with one-stage prepectoral PU foam-coated implant reconstruction were performed. Out of 50 patients, 6 required surgical revision within 30 days, because of hematoma (2), wound dehiscence (2) infection (1), and full thickness nipple-areolar complex (NAC) necrosis (1). Four patients developed a cutaneous rash with spontaneous resolution. Statistical analysis showed a significant influence of hypothyroidism and previous radiotherapy on the risk of complications. The association with prior radiotherapy (pRT) was not significant using binary logistic regression. When excluding oncological reasons and patient's wish for NAC excision, our decision to perform an NSM was influenced by breast cup size, preoperative measurements, and breast weight.

CONCLUSIONS

Early experience with immediate prepectoral DTI reconstruction with PU-covered implants alone suggests that it is a reliable procedure. Prior breast irradiation does not increase postoperative complication rates in our series. NAC preservation was decided according to preoperative lower breast measurements.

Chest Masculinization Technique and Outcomes in 72 Double-incision Chest-contouring Procedures with Free Nipple Grafting

Background:

Chest masculinization for gender affirmation is the removal of breast tissue and excess skin, often with repositioning of the nipple areola complexes to achieve a male-appearing chest. A double-incision technique with free nipple grafting (FNG) is the preferred method for trans men with large, ptotic breasts. The authors present the outcomes of 72 consecutive chest masculinization cases using this technique.

Methods:

A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (JDK). Patients who underwent masculinization by concentric circle or liposuction-only techniques were excluded. Potential risk factors for complications were analyzed with Chi-square and logistic regression techniques. P < 0.05 was considered significant.

Results:

Seventy-two patients underwent bilateral mastectomy with free nipple grafting. There were 6 major complications resulting in return to operating room, re-admission, or need for interventional procedure. These included 4 hematomas, 1 infection, and 1 hospital admission for shortness of breath and pain.

Minor complications treated conservatively included 3 seromas, 1 instance of delayed wound healing, 1 case of superficial thrombophlebitis, and 4 hypertrophic scars. Eleven patients experienced nipple areolar complex complications. Four patients underwent revision surgery. Nicotine use was associated with a higher rate of hematoma (χ2: 9.95, P = 0.007). Later operative date, a surrogate for experience, was associated with decreased return to the operating room (Odds ratio: 0.99, P = 0.025).

Conclusion:

Double-incision chest contouring with free nipple grafting provides good chest contour for transgender men,

with low complication rates.

Effect of contralateral augmentation on postoperative complications after the second stage of tissue expander/implant breast reconstruction

Background

Contralateral augmentation mammoplasty in implant-based reconstruction could potentially lead to deterioration of the thickness of the mastectomy skin flap and increase postoperative complications of the reconstructed breast. We compared the complication rates of the reconstructed breast in the augmentation and no-augmentation groups among patients undergoing tissue expander/implant breast reconstruction.

Methods

Patients who underwent mastectomy followed by tissue expander/implant breast reconstruction between February 2010 and April 2018 were retrospectively reviewed. The primary outcome measures were complications and the need for a revision operation. The augmentation and no-augmentation groups underwent propensity score-matched analysis and the matched cases underwent multivariable logistic regression analysis.

Results

From the 234 patients in the augmentation group and 517 patients in the no-augmentation group, 200 propensity score-matched pairs were obtained. Analysis of the matched pairs revealed that the augmentation group as compared to the no-augmentation group showed a significantly higher overall complication rate (13.5 percent versus 6.5 percent; P=0.025) and revision operation rate (9.0 percent versus 3.0 percent; P=0.019). Multivariable conditional logistic regression analyses of the matched cases revealed that contralateral augmentation (odds ratio, 3.457; 95% confidence interval, 1.039-11.498; P=0.043) was associated with increased odds for a revision operation of the reconstructed breast.

Conclusions

This study investigated the postoperative complications of the reconstructed breast associated with contralateral augmentation mammoplasty in patients who underwent mastectomy followed by tissue expander/implant breast reconstruction. The augmentation group had a higher revision operation rate than did the no-augmentation group. A clinical evaluation of the risks and benefits of contralateral augmentation and preoperative counseling may be indicated for patients who are undergoing implant-based breast reconstruction and are candidates for contralateral augmentation mammoplasty.

Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction

Background

Nipple-sparing mastectomy (NSM), followed by immediate reconstruction (IR) of the breast, has become a preferred surgical procedure with good cosmesis results and patient satisfaction. However, nipple-areolar complex (NAC) ischemia and necrosis remain major problems after NSM and IR.

Methods

We retrospectively analyzed patients who underwent NSM and IR at Gangnam Severance Hospital from January 2009 to June 2018. We compared the patient characteristics and complication rate among three different incisions (inframammary fold [IMF], radial, periareolar). Additionally, we identified the risk factors of NAC necrosis.

Results

Data from 290 eligible breasts in 275 patients were analyzed. Patients with IMF incision had relatively lower breast weights. The overall complication rate was the highest with periareolar incision and the lowest with IMF incision (42.6% vs. 18.8%, p < 0.001). The rate of NAC ischemia or necrosis was significantly different among the three incisions (9.7%, 17.0%, and 31.1% in IMF, radial, and periareolar, respectively; p < 0.001). Moreover, surgical treatments were more frequently needed in patients with periareolar incision. Periareolar incision, short distance from the tumor to the nipple base, and large breast weight were independent risk factors of NAC ischemia or necrosis in multivariable analysis.

Conclusions

Compared with IMF incision, periareolar incision was associated with higher incidences of surgical complications and NAC necrosis. Careful consideration is needed when planning NSM in patients with a large breast volume or a tumor close to the nipple.

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Periareolar incision shows higher complication rate in nipple-sparing mastectomy.

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Periareolar incision is a risk factor for nipple-areolar complex necrosis.

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Other risk factors include tumor-nipple distance and breast weight.

Skin-sparing Mastectomy and Immediate Nipple Graft for Large, Ptotic Breast

Nipple-areolar skin-sparing mastectomy followed by autologous reconstruction in patients with large, ptotic breasts often offers a limited field, resulting in strenuous traction. Skin-sparing mastectomy (SSM) with immediate nipple grafting from the specimen was attempted for such patients. Patients who underwent SSM with immediate autologous breast reconstruction and nipple grafting between September 2016 and February 2019 were evaluated, including 33 nipple grafts in 30 patients. The average weight of the mastectomy specimen was 552.5 g and the average operation time for unilateral mastectomy was 109 minutes. No complete nipple loss or major skin flap necrosis was reported. Adjuvant therapy started after an average of 24 days. SSM with immediate nipple grafting on the autologously reconstructed breast could be an alternative for large, ptotic breasts. It is also useful for patients requiring contralateral balancing procedures or those with bilateral breast cancer in which only one nipple can be spared oncologically.