Modified Lower Pole Autologous Dermal Sling for Implant Reconstruction in Women Undergoing Immediate Breast Reconstruction after Mastectomy

BRM: From Skin-Reducing Mastectomy to the New Concept of Breast Reshaping Mastectomy

Background: Macromastia is a well-known issue in breast reconstruction. Skin-reducing mastectomy (SRM) was introduced as a skin-sparing mastectomy that utilizes a skin reduction pattern similar to breast reduction or breast lift surgery, specifically to manage hypertrophic and pendulous breasts. Over time, numerous authors have contributed to refining the SRM technique, leading to the development of various technical variants. However, the diversity of approaches inspired by SRM has created confusion, and clear surgical indications are lacking. Methods: We propose a unifying concept called breast reshaping mastectomy (BRM), which encompasses all techniques based on SRM principles. The BRM aims not only to preserve and reduce the breast skin envelope but also to immediately reshape it for a more aesthetic outcome. This approach is applicable to all mastectomies where skin envelope preservation (with or without the nipple-areola complex) is oncologically safe, a modification of breast skin coverage is needed for better aesthetic results, and an implant-based reconstruction is planned. Results: To define the BRM concept, we reviewed the existing literature on SRM and its related techniques. Our analysis focused on four key elements: skin incision pattern, implant coverage strategy, nipple-areola complex (NAC) management, and the choice between two-stage and direct-to-implant reconstruction. Conclusions: By integrating these four components into a single surgical framework, BRM provides a structured approach to breast reconstruction that enhances both oncologic safety and aesthetic outcomes. Standardizing these techniques could help clarify surgical indications and improve reconstructive planning for patients undergoing skin-sparing mastectomy.

Advanced Autologous Lower Dermal Sling Technique for Immediate Breast Reconstruction Surgery in Small and Non-ptotic Breasts

Breast reconstruction with an autologous lower dermal sling (ALDS) is an established one-stage procedure in patients with moderate to large ptotic breasts. However, this technique is difficult to perform in small and non/minimally ptotic breasts. We describe our experiences from a single institution about a novel Advanced Autologous Lower Dermal Sling (A-ALDS) technique for reconstruction in small breasts. We performed one-stage nipple/skin sparing mastectomies in 61 patients with immediate reconstruction either by Conventional Immediate Breast Reconstruction Surgery or A-ALDS technique. Mean age of study patients was 46.9 years. We observed significantly better cosmetic score and lower immediate complication rate vis-a-vis skin necrosis, implant loss with the A-ALDS technique (i.e., nil versus 3 in Conventional Immediate Breast Reconstruction Surgery (IBRS)). Forty patients completed 12-month follow-up. The PROMs - Patient Reported Outcome Measures (Breast-Q) revealed good to excellent scores for satisfaction with breast, cosmetic outcome, and psychosocial well-being in patients operated with both these techniques. However, sexual well-being was significantly better in the A-ALDS group. The A-ALDS is a novel, cost-effective, and safe technique for immediate one-stage implant-based reconstruction for small breasts. It provides a dermal barrier flap and hence, ensures less complications, excellent cosmetic results, and patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01524-8.

Bilateral Risk-Reducing Prophylactic Mastectomies in an Unaffected BRCA1 Carrier Using Dermal Sling and Implant

Hereditary breast cancer (HBC) accounts for 5-10% of all breast cancer patients. Mutations in BRCA 1 and 2 are the most common culprits of HBC. These patients have a much higher lifetime risk of developing breast cancer than the non-carriers. Thus these high-risk patients qualify to receive risk-reducing measures in form of close surveillance, chemoprophylaxis, or sometimes even risk-reducing surgeries in high penetrance mutation carriers. We report a case of bilateral risk-reducing prophylactic mastectomies (B/L RRM) and bilateral risk-reducing salpingo-oophorectomy (B/L RRSO) performed in a 37-year-old healthy BRCA 1 carrier. Although, this is an age-old practice, its acceptance in India has been low for reasons such as cost of surgery, social stigma, lack of awareness, fear of visiting an oncology clinic, surgery and reconstruction, or loss of a healthy organ; and more acceptance towards other risk reduction methods.

Breast conservation surgery & oncoplasty in India - Current scenario

Breast cancer incidence is on the rise in India as in rest of the world. While the advances in overall cancer care are at par, the surgical interventions have not been changing at the same pace in India, as in the rest of the developed world. Partly, this is due to the relatively more advanced state of cancer at detection and partly due to lack of awareness resulting in apprehension and slow acceptance of de-escalation of surgical interventions by the treating surgeons, and the beneficiaries, the patients. The article looks at the current scenario, available evidence on the practices and pitfalls with possible solutions for advancing surgical care of breast cancer in India.

Pushing the Envelope: Skin-Only Mastopexy in Single-Stage Nipple-Sparing Mastectomy with Direct-to-Implant Breast Reconstruction

BACKGROUND

Despite advances in skin envelope reduction techniques and experienced nipple-sparing mastectomy flap procedures, the rate of nipple malposition and secondary revision in these patients remains high and eligible candidates are limited. In this article, the authors present a novel technique combining skin reduction nipple-sparing mastectomy surgery with single-stage skin-only mastopexy and direct-to-implant reconstruction.

METHODS

A retrospective review was performed at a single institution from 2015 to 2018. All patients were operated on using this technique consecutively, by a breast and plastic surgeon team (A.F. and A.M.). Surgical technique and outcomes were compared with the currently accepted literature.

RESULTS

Twenty-six patients (40 breasts) underwent this technique; all were single-stage direct-to-implant reconstructions. The average body mass index was 31 kg/m2. A Wise pattern was used in 35 breasts (87.5 percent) and prepectoral placement was used in 25 breasts (62.5 percent). Overall complications included seroma [n = 6 (15 percent)], vertical/T-junction dehiscence [n = 4 (10 percent)], skin necrosis [n = 4 (10 percent)], superficial or partial nipple necrosis [n = 4 (10 percent)], with no total nipple-areola complex lost and no reconstructive failures at 18.7 months' average follow-up.

CONCLUSIONS

In this article, the authors share a novel reconstructive technique in which the skin envelope is reduced, the nipple-areola complex is repositioned, and a direct-to-implant reconstruction is performed in a single stage at the time of mastectomy. Consideration of pearls and pitfalls accompanies a review of the authors' experienced complication profile, and is discussed in the context of current literature.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Breast reconstruction with a dermal sling: a systematic review of surgical modifications

A dermal sling (DS) is used to cover the implant with two layers of tissue when immediate breast reconstruction is performed in women with large and ptotic breasts. It works as an autologous acellular dermal matrix/mesh that can be used to control the implant pocket and inframammary fold, without inferring an extra foreign material and higher costs. There is relatively little published about the DS technique. The primary aim of this study was to systematically review published surgical modifications to the dermal sling (DS). The secondary aim was to investigate what implants have been used. Relevant databases were searched for articles and abstracts published between January 1990 and September 2018. Inclusion criteria were studied and case reports on DS meeting the criteria defined in a PICO. Review articles were excluded. Total evidence for the different types of DSs was graded according to GRADE. A total of 428 abstracts were retrieved. Of these 373 abstracts did not meet the inclusion criteria and were excluded, leaving 54 abstracts. Nine categories of surgical modifications could be identified: classic dermal sling (DS) with minor modifications, non Wise-pattern mastectomy DS, nipple areola complex bearing DS, DS in combination with a matrix/mesh, DS as a suture line protection technique, DS with a modified circulatory basis, DS without an implant, DS as an immediate-delayed technique and pre-pectoral DS. The evidence for DS as a surgical technique is very low (GRADE ⊕). The DS can be used with both permanent implants and tissue expanders (GRADE ⊕).