Delayed two-stage nipple sparing mastectomy and simultaneous expander-to-implant reconstruction of the large and ptotic breast

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Correction of Breast Ptosis in Immediate Breast Reconstruction

Nipple-sparing mastectomy is psychologically advantageous and can result in superior cosmetic outcomes. However, nipple position adjustment is challenging, and ischemic complications may arise. For patients who require timely mastectomies and reconstructions, concurrent mastopexy may prevent nipple malposition and reduce the risk for future corrections.

Methods

A retrospective chart review of all patients undergoing immediate prosthetic reconstruction after nipple-sparing mastectomy were analyzed. Data regarding patient characteristics; surgical indications; reconstructive modality, including presence or absence of simultaneous nipple lift; and early and late complications were examined.

Results

In total, 142 patients underwent 228 nipple-sparing mastectomies and prosthetic reconstructions. Correction of ptosis (lift) was performed in 22 patients and 34 breasts. The remaining 122 patients and 194 breasts did not receive mastopexy (no-lift). Two patients received bilateral reconstructions involving both lift and no-lift. Comparing the lift and no-lift cohorts demonstrated no differences in major complications (47.1% versus 57.7%; P = 0.25) and minor complications (76.5% versus 74.7%; P = 0.83). Control for plane of implant placement also did not show differences in major (P = 0.31) or minor (P = 0.97) complications. Similarly, control of application of acellular dermal matrix found major (P = 0.25) and minor (P = 0.83) complications uniform and not affected by lift status. Nipple lift distance was not associated with increased major (P = 0.10) complications.

Conclusion

Simultaneous correction of nipple position in immediate prosthetic breast reconstruction seem safe with uniform complications rates that are unaffected by acellular dermal matrix use or plane of implant placement.

Mastopexy Strategies for Ptotic Breasts in Patients Choosing Autologous Reconstruction Following Prophylactic Mastectomy

BACKGROUND

Autologous breast reconstruction is a reliable solution for many patients after mastectomy. While this technique represents a standardized approach in many patients, patients with ptotic breasts may require a combination of procedures to achieve an aesthetically pleasing result.

METHODS

We reviewed the mastectomy and free-flap breast reconstruction procedures performed at our institution from 2018 to 2022 in patients with ptotic breasts. The technique used to address the ptosis was put in focus as we present the four strategies used by our reconstructive surgeons. We performed two different one-stage and two different two-stage procedures. The difference between the two-stage procedures was the way the nipple areola complex was treated (inferior dermal pedicle or free skin graft). The difference between the one-stage procedures was the time of execution of the mastopexy/breast reduction (before or after the mastectomy and autologous breast reconstruction).

RESULTS

The one-stage procedure was performed with a free NAC in three patients and with a pedicled NAC in five patients. The two-stage procedure was performed in seven patients, with six of them undergoing mastopexy before and one patient undergoing mastopexy after the bilateral mastectomy and autologous reconstruction. No flap loss or total loss of the nipple areola complex occurred. Partial NAC loss was observed in five breasts in the single-stage group without any occurrence in the double-stage group.

CONCLUSIONS

While both one- and two-stage procedures were performed in a safe fashion with satisfactory results at our institution, larger trials are required to determine which procedure may yield the best possible outcomes. These outcomes should also include oncological safety and patient-reported outcomes.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review

PURPOSE

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.

METHODS

We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.

RESULTS

Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.

CONCLUSION

ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Application of Acellular Dermal Matrix in Gynaecology—A Current Review

The aim of our study is to draw attention to the multitude of applications of acellular dermal matrix (ADM) in the surgical treatment of urogynaecological disorders, such as reduction in the reproductive organs, and in reconstructive gynaecology. Despite the existence of numerous operational methods and materials, the effectiveness of transvaginal operation is still insufficient. Native tissue operations are often not durable enough, while operations with synthetic materials have numerous side effects, such as infections, hematomas, vaginal erosion, or dyspareunia. Hence, the search continues for a different material with a better efficacy and safety profile than those previously mentioned. It seems that ADM can meet these requirements and be a useful material for urogynaecological surgery. Key words related to the usage of ADM in gynaecological reconstructive surgery were used to search relevant databases (NCBI MedLine, Clinical Key, Clinicaltrials.gov). This manuscript is based on 43 literature sources, 28 (65.11%) of which were released after 2016. Older sources are cited for the purpose of presenting basic science, or other important issues related to the manuscript. ADM seems to be an ideal material for urogynaecological and reconstructive surgery. It has high durability, and thus high effectiveness. Moreover, it does not have the side effects typical for synthetic materials. There are no reports of material rejection, erosion or dyspareunia directly related to the presence of the mesh. Due to the difficulties in obtaining ADM and the need to perform additional tests, this material is not common in routine clinical practice. Therefore, the number of cases and the size of the research groups are insufficient to clearly define the potential of mesh from biological tissue. However, the results are so promising that it is worth considering a wider introduction to the use of this material. Our hope is that increasing clinicians’ awareness of this topic will lead to more studies comparing methods using native tissues or synthetic materials and those using ADM.