Revascularization of the Nipple-Areola Complex following Nipple-Sparing Mastectomy

Extreme Nipple-Sparing Mastectomy: Feasibility of Nipple Preservation and Immediate Reconstruction in Breasts Weighing Over 600 Grams in a Cohort of 43 Patients

Background: Limited data exist on complication rates in nipple-sparing mastectomy (NSM) in patients with large-volume breasts. Our aim was to evaluate the early complication rates of NSM with immediate reconstruction in a consecutive cohort of patients with large-volume breasts. Methods: After IRB approval, patients treated with prophylactic or therapeutic NSM and immediate reconstruction from January 2020 to June 2022 at our health network were identified. Patients with breast weights > 600 g (the extreme NSM group) were compared to patients with breast weights of 600 g or less (the average-volume NSM group). Results: A total of 184 patients underwent NSM with immediate reconstruction. Forty-three of 184 (23.37%) NSM patients had breast weights > 600 g. Of these, 30 patients had bilateral NSM, for a total of 73 breasts with volumes over 600 g, ranging from 603 to 1658 g. There were significantly more total complications in the extreme NSM compared to average-volume NSM groups (41.86% vs. 21.99%, p=0.009852). When broken down into major and minor complications, the extreme NSM group had significantly more major complications than the average-volume NSM group (27.91% vs. 12.86%, p=0.01072), but no difference in minor complications (13.95% vs. 9.29%, p=0.2205). Overall, one (2.33%) patient in the extreme NSM group had a reconstruction failure, compared to three (2.14%) in the average-volume NSM group. Only two of 43 (4.65%) patients in the extreme NSM group lost their nipples due to total or partial nipple necrosis. Conclusions: NSM with immediate reconstruction was successful in the majority of patients with large-volume breasts. The rate of nipple loss was acceptably low. Women with breast volumes larger than 600 g who are motivated to save their nipples at the time of mastectomy could be offered NSM.

A New Dissection Sequence, Based on Mapping Perforators of Pectoralis Major

BACKGROUND

Breast augmentation remains a leading cosmetic surgical procedure. Over the past two decades, various benefits and complications of pocket selection techniques have been described for breast augmentations. However, there has been limited evolution in the dissection technique sequence initially described by Tebbetts in his seminal publication.

OBJECTIVE

We studied in detail the vascular anatomy of the pectoralis major and breast. We related the findings of anatomical dissections with the conclusions obtained by imaging and developed a systematic dissection sequence for creating a bloodless submuscular pocket.

METHODS

Breast dissection was performed on ten fresh-frozen cadaveric tissues to observe vascular distribution mapping of the dual-plane pocket associated with the subpectoral space, and we replicated it in 727 female patients aged 18-66 years undergoing primary breast augmentation with a dual-plane pocket implant placement using a specific dissection sequence. Surgical data, implant information, patient demographics, and complications were systematically collected.

RESULTS

The mean patient age was 30 years. Round implants were used exclusively, with 80.05% textured and 19.95% smooth. Implant sizes ranged widely from 150 cc to 450 cc. We identified the presence of eight perforator vessels within the breast in the cadaver dissections and observed a large retropectoral avascular space. These findings are correlated with the images obtained with indocyanine green (ICG). Consequently, we described four retropectoral zones based on the mapping of the perforators. Importantly, this approach significantly reduced the incidence of possible postoperative hematomas, demonstrating its potential to improve surgical outcomes.

CONCLUSION

This practical dissection sequence of the four retropectoral zones aims to shorten our learning curve for precision, safe, and a bloodless retro-muscular pocket dissection.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Omega Mastopexy Technique for the Correction of Breast Ptosis after Breast Implant Explantation

Background

The past few years have seen a 50% increase in breast implant explantations. Patients with ptotic breasts may desire mastopexy, although conventional techniques are often invasive. We describe our experience with the omega mastopexy technique after breast implant explantation and capsulectomy.

Methods

In the past 2 years, 10 patients with breast Regnault classification ptosis grade I-III underwent the omega mastopexy technique following breast implant explantation and capsulectomy. A detailed description of our operating technique is provided.

Results

This series includes a total of 10 patients. The median age was 48.5 (IQR 42.8-52.5), median body mass index 26 (23.8-28.3) and median implant volume 355 (IQR 325-375). Excellent and stable aesthetic results were achieved without recurring ptosis. One patient, an active smoker, underwent reexcision after 1 year due to hypertrophic scars. No complications have been reported until this date at 2 years follow-up.

Conclusions

The omega mastopexy technique offers an excellent alternative to classic lifting techniques for ptotic breasts after breast implant explantation. Patients with increased risk of wound healing impairment are especially likely to benefit.

Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy

BACKGROUND

Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results.

OBJECTIVES

The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients.

METHODS

We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest.

RESULTS

We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved.

CONCLUSIONS

The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy.

LEVEL OF EVIDENCE: 3

Careful Where You Cut: Strategies for Successful Nerve-preserving Mastectomy

Breast neurotization represents an evolving technique that is not widely practiced in most centers specializing in breast cancer treatment. Recognizing the limited educational resources available for breast and plastic surgeons concerning mastectomy techniques that emphasize nerve preservation, our study sought to bridge this gap. Specifically, we aimed to provide a comprehensive exploration of the surgical applied anatomy of breast sensory innervation and a detailed, step-by-step guide for incorporating nerve-sparing mastectomy and breast neurotization into clinical practice. The significance of this work lies in its potential to enhance the understanding and implementation of nerve-preserving techniques in mastectomy procedures, contributing to improved patient outcomes and quality of life post surgery. We hope that by familiarizing breast and reconstructive surgeons with this procedure, we can gain momentum in our research efforts and ultimately enhance the care provided to mastectomy patients.

Implant-Based Breast Reconstruction After Nipple-Sparing and Skin-Sparing Mastectomy in Breast-Augmented Patients: Prepectoral or Submuscular Direct-to-Implant Reconstruction?

BACKGROUND

Patients with breast augmentation facing a breast cancer diagnosis pose unique challenges for both breast and plastic surgeons in terms of treatment and reconstruction. Traditional submuscular direct-to-implant (DTI) breast reconstruction is often considered the standard approach, regardless of the previous implant pocket. However, recent trends in prepectoral reconstruction provide an innovative solution for patients with previous subglandular and submuscular implants.

OBJECTIVES

In this study we aimed to share our experiences with DTI breast reconstruction in patients with a history of breast augmentation, with a specific focus on the viability of prepectoral reconstruction.

METHODS

A retrospective review was conducted on 38 patients with previous breast augmentation who underwent either skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer followed by DTI reconstruction between January 2015 and July 2023. Our analysis considered various factors, including previous implant positioning, capsular and implant status, and mastectomy flap thickness (MFT), offering insights into the rationale behind choosing the new implant positioning.

RESULTS

Patients with a history of subglandular breast augmentation and an MFT greater than 1 cm were candidates for prepectoral reconstruction. When the MFT was less than 1 cm but flap vascularity was sufficient, a prepectoral reconstruction was performed; otherwise, retropectoral reconstruction was preferred. Patients with submuscular breast augmentation were evaluated similarly, with submuscular reconstruction chosen when the MFT was less than 1 cm and prepectoral reconstruction preferred when the MFT exceeded 1 cm.

CONCLUSIONS

Immediate prepectoral DTI reconstruction represents a feasible option for specific patients with a history of breast augmentation. Decisions regarding the reconstructive approach are influenced by variables such as mastectomy flap thickness, implant status, and capsular conditions.

LEVEL OF EVIDENCE: 3

One-Stage Implant-Based Breast Reconstruction With Polyurethane-Coated Device: Standardized Assessment of Outcomes

BACKGROUND

Nipple-sparing mastectomies (NSMs) and implant-based breast reconstructions have evolved from 2-stage reconstructions with tissue expansion and implant exchange to direct-to-implant procedures. In this study, we tested safety and efficacy of polyurethane-based implants according to standard assessment tools.

OBJECTIVES

This study aimed to test safety and feasibility of polyurethane-coated implants with standardized assessment employing internationally acknowledged evaluation criteria.

METHODS

Cases of NSMs followed by breast reconstruction in 1 stage with immediate prepectoral polyurethane-coated implant placement were retrospectively reviewed. Preoperative characteristics of the population have been collected. Adherence to quality assurance criteria of the Association of Breast Surgery-British Association of Plastic Reconstructive and Aesthetic Surgeons was verified. Complications were assessed with the Clavien Dindo classification, modified for the breast. Rippling, implant rotation, and malposition were also evaluated.

RESULTS

Sixty-three consecutive patients underwent 74 NSMs and immediate breast reconstruction with micro polyurethane foam-coated anatomic implants. In 5 cases we had unplanned readmissions with return to the operating room under general anesthesia (6.7%) and implant loss within 3 months from breast reconstruction (5 implants, 6.7%). Postoperative complications according to Clavien Dindo were grade 1 in 6 cases (8.1%), grade 2 in 3 cases (4%), and 3b in 5 cases (6.7%).

CONCLUSIONS

Polyurethane-coated implants may prevent rotation and malposition and capsular contracture in the short term. Unplanned readmission rates and implant loss rates in the short term may be slightly higher.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, Chinese, and Taiwanese online here: https://doi.org/10.1093/asj/sjad301.

LEVEL OF EVIDENCE: 4

When to Consider Prepectoral Implant Conversion After Subpectoral Implant Breast Reconstruction and How to Plan It

Many deformities occur after subpectoral implant-based breast reconstruction. Today, immediate prepectoral reconstruction with implants shows a significant increase in popularity because it has many advantages over subpectoral positioning: absence of muscle deficit and breast animation deformity, reduced implant dislocation, and less postoperative pain and easy recovery. Implant pocket conversion from the submuscular to prepectoral plane has become our preferred strategy for solving most problems related to the submuscular implant position. The authors performed a retrospective review (from June 2018 to December 2022) of patients who underwent prepectoral implant conversion for correction of animation deformity, dysfunctional chronic pain, or to ameliorate poor cosmetic results. Acellular dermal matrix (ADM) was utilized in the first 7 cases; in the remaining 56 patients polyurethane-covered implants were placed. Resolution of animation deformity and chronic pain were evaluated, as were cosmetic results and any postoperative complications. Sixty-three patients (87 breasts) underwent prepectoral implant conversion with complete resolution of animation deformity and chronic pain as well as improved cosmetic results. Preventive lipofilling was done in 18 patients. Complication rate included 3 periprosthetic seromas in ADM group. All resolved after ultrasound-guided aspiration. Rippling was noted in 3 patients, and edge visibility was documented in 1 patient. There were no incidences of grade 3 or 4 capsular contracture. The prepectoral implant conversion improves functional and aesthetic results, reaching excellent outcomes. Preparation for this surgery with fat grafting is considered a complementary procedure that increases the indications for prepectoral implant conversion.

LEVEL OF EVIDENCE: 4

Sensory Evaluation of the Nipple-Areolar Complex Following Primary Breast Augmentation: A Comparison of Incision Approaches

BACKGROUND

The central inframammary incisional approach for breast augmentation surgery disrupts the fifth anterior intercostal nerve-artery-vein-plexus. The authors hypothesized that preservation of the fifth anterior intercostal neurovascular pedicle might completely preserve nipple-areola complex (NAC) sensitivity after implant breast augmentation.

OBJECTIVES

The aim of the study was to analyze if the use of a laterally displaced incision achieves better sensitivity results than the conventional median submammary incision in females who underwent primary breast augmentation surgery.

METHODS

A group of 25 female patients (50 breasts) underwent a surgical protocol for primary prepectoral implant breast augmentation with a laterally displaced submammary incision. This group was compared to a similar group of 25 patients (50 breasts) who underwent breast augmentation through a conventional submammary central approach. Sensitivity testing with Semmes-Weinstein monofilaments was performed in both groups preoperatively and on postoperative days 2, 14, and 30, and after 6 months.

RESULTS

Both groups were similar in age, BMI, comorbidities, and implant volumes. Preoperatively, all patients reported normal sensory function in both breasts. Postoperatively, in the laterally displaced incision group, sensory function remained normal in NAC areas, whereas in the conventional incision group, all cases presented the same degree of sensitivity diminution at Days 2, 14, and 30 (P = .000). At 6 months, all values were the same as at Day 30.

CONCLUSIONS

Preservation of the fifth AIC pedicle resulted in complete preservation of preoperative NAC sensitivity. The laterally placed inframammary incision should be considered for patients undergoing primary prepectoral implant breast augmentation.

LEVEL OF EVIDENCE: 4

Optimizing Acellular Dermal Matrix Integration in Heterologous Breast Reconstructive Surgery: Surgical Tips and Post-Operative Management

Background and Objective: Prepectoral implant placement in breast reconstruction is currently a must-have in the portfolios of breast surgeons. The introduction of new tools and conservative mastectomies is a game changer in this field. The prepectoral plane usually goes hand-in-hand with the ADM wrapping of the implant. It is a cell-free dermal matrix comprising a structurally integrated basement membrane complex and an extracellular matrix. The literature reports that ADMs may be useful, but proper patient selection, surgical placement, and post-operative management are essential to unlock the potential of this tool, as these factors contribute to the proper integration of the matrix with surrounding tissues. Materials and Methods: A total of 245 prepectoral breast reconstructions with prostheses or expanders and ADMs were performed in our institution between 2016 and 2022. A retrospective study was carried out to record patient characteristics, risk factors, surgical procedures, reconstructive processes, and complications. Based on our experience, we developed a meticulous reconstruction protocol in order to optimize surgical practice and lower complication rates. The DTI and two-stage reconstruction were compared. Results: Seroma formation was the most frequent early complication (less than 90 days after surgery) that we observed; however, the majority were drained in outpatient settings and healed rapidly. Secondary healing of wounds, which required a few more weeks of dressing, represented the second most frequent early complication (10.61%). Rippling was the most common late complication, particularly in DTI patients. After comparing the DTI and two-stage reconstruction, no statistically significant increase in complications was found. Conclusions: The weakness of prepectoral breast reconstruction is poor matrix integration, which leads to seroma and other complications. ADM acts like a graft; it requires firm and healthy tissues to set in. In order to do so, there are three key steps to follow: (1) adequate patient selection; (2) preservative and gentle handling of intra-operative technique; and (3) meticulous post-operative management.