Immediate Nipple-Areolar Complex Reconstruction for Patients Undergoing Implant-Based Reconstruction or Therapeutic Mammoplasty

Immediate Nipple Reconstruction in Skin-sparing Mastectomy with A Modified Wise-pattern Design

This article discusses a novel approach to immediate nipple reconstruction during skin-sparing mastectomy with Wise-pattern design, a common procedure in direct-to-implant breast reconstruction. Traditionally, nipple reconstruction is performed as a second procedure, incurring additional costs and potential complications. This novel technique involves a simple modification to the Wise-pattern flap during the initial mastectomy, allowing for one-step reconstruction. The procedure includes preoperative markings of the Wise-pattern design, with a U-shaped flap added at the top angle to create the nipple position. This U-shaped flap, containing both skin and subcutaneous tissue, is then folded over itself and sutured, resulting in an inverted T-shaped incision with the reconstructed nipple at the apex. This article emphasizes the avoidance of a secondary operation for nipple reconstruction, avoiding additional costs and potential complications associated with flap loss, especially in postradiation patients. The technique was applied to five consecutive cases, with patient satisfaction reported as very high. Follow-up at 6 months showed no venous congestion or flap loss, and in patients without adjuvant radiation, the reconstructed nipple maintained almost all its initial postoperative height. Minor loss of nipple protrusion over time was comparable to traditional nipple reconstruction (eg, skate flap), and the construction of the new nipple required only an average of 10 extra minutes. Although larger-scale studies are needed for a comprehensive evaluation, the preliminary results suggest promising outcomes and encourage larger-scale safety and outcomes studies of this technique in Wise-pattern skin-sparing reconstructions.

Nipple-Areola Complex Reconstruction Using a Skin Graft and Nipple Sharing after Wise-pattern Central Lumpectomy

Patients with central breast cancers historically underwent mastectomy, as the aesthetic implications of removing the nipple–areola complex and central breast tissue left disfiguring defects after breast conservation. The introduction of oncoplastic techniques allowed for central lumpectomies in ptotic patients, as the excess skin and gland could be mobilized centrally to fill the defect and even immediately reconstruct a nipple and areola. These reconstructions used excess skin on the Wise pattern vertical limbs to create a nipple, or on a “neopedicle” where both the areola and nipple were reconstructed and then mobilized superiorly into position as would be performed for a conventional mastopexy or reduction. These techniques importantly allowed for the immediate reconstruction of a nipple and areola in patients who often imminently required radiotherapy and where subsequent surgery would be challenging. Here we describe another option for immediate nipple and areola reconstruction in these patients—nipple sharing and a skin graft—a well-established approach in post-mastectomy patients but never previously described for patients undergoing breast conservation.

Analysis of Secondary Surgeries after Immediate Breast Reconstruction for Cancer Compared with Risk Reduction

Background:

This study sets out to compare reconstructive practice between patients undergoing immediate breast reconstruction (IBR) for cancer and those who opted for risk reduction (RR), with an emphasis on examining patterns of secondary surgery.

Methods:

Data collection was performed for patients undergoing mastectomy and IBR at a teaching hospital breast unit (2013–2016).

Results:

In total, 299 patients underwent IBR (76% cancer versus 24% RR). Implant-based IBR rate was similar in both groups (58% cancer versus 63% RR). Reconstruction loss (5.3% cancer versus 4.2% RR) and complication (16% cancer versus 12.9% RR) rates were similar. Cancer patients were more likely to undergo secondary surgery (68.4% versus 56.3%; P = 0.025), including contralateral symmetrization (22.8% versus 0%) and conversion to autologous reconstruction (5.7% versus 1.4%). Secondary surgeries were mostly planned for cancer patients (72% planned versus 28% unplanned), with rates unaffected by adjuvant therapies. This distribution was different in RR patients (51.3% planned versus 48.7% unplanned). The commonest secondary procedure was lipomodeling (19.7% cancer versus 23.9% RR). For cancer patients, complications resulted in a significantly higher unplanned secondary surgery rate (82.5% versus 38.8%; P = 0.001) than patients without complications. This was not evident in the RR patients, where complications did not lead to a significantly higher unplanned surgery rate (58.9% versus 35.2%; P = 0.086).

Conclusions:

Most of the secondary surgeries were planned for cancer patients. However, complications led to a significantly higher rate of unplanned secondary surgery. Approximately 1 in 4 RR patients received unplanned secondary surgery, which may be driven by the desire to achieve an optimal aesthetic outcome.

Update in Direct-to-Implant Breast Reconstruction

Implant-based reconstruction (IBR) remains the most commonly utilized breast reconstruction option for post-mastectomy patients. IBR can be approached as either a one-stage reconstruction or a two-stage reconstruction. Facilitated by improvements in surgical technology and advanced techniques, one-stage reconstruction, also known as direct-to-implant (DTI) reconstruction, involves the insertion of an implant at the time of mastectomy. The decision to pursue either a DTI or a two-stage reconstruction is based on several factors, including the patient's overall health, expected risk of postoperative complications, and associated costs to both the patient and hospital.