Faculty Bibliography

Ischemic complications after immediate breast reconstruction have devastating consequences; however, individual risk assessment remains challenging. We seek to develop an intraoperative assessment tool to assist in estimating risk of ischemic complications in immediate breast reconstruction.

BACKGROUND:Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking. METHODS:A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes. RESULTS:Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort. CONCLUSION/CONCLUSIONS:In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Immediate breast reconstruction relies on healthy mastectomy flaps for success. Tissue perfusion of these mastectomy flaps is dependent on multiple patient-, operative-, and surgeon-specific factors, which must be optimized. Unfortunately, tissue perfusion is also notoriously difficult to accurately assess and investigate. In this review, we discuss the importance of tissue perfusion in successful reconstructive breast surgery with an emphasis on perfusion assessment and techniques to ensure that anatomic mastectomy flap perfusion is maintained for immediate breast reconstruction after mastectomy. Preoperative and patient-specific factors should be considered with operative plans modified to minimize ischemic risk. Intraoperatively, incision planning and mastectomy dissection will dictate skin flap perfusion. Most importantly, mastectomy dissection in a plane at the breast capsule will maximize preservation of the subdermal plexus and subcutaneous perforators that supply the breast skin envelope while also maximizing oncologic parenchymal resection. Such anatomic dissection has been demonstrated to decrease risk of ischemic complications in immediate breast reconstruction. Postoperatively, any potential or actual areas of impaired perfusion and ischemia must be diagnosed appropriately and managed proactively to ensure a successful reconstruction. It is also important for surgeons to be aware of imaging modalities and adjunctive technologies that can help promote and assess optimal mastectomy flap tissue perfusion. Plastic surgeons and breast surgeons must actively and collaboratively work together to ensure their mutual goals are met, and optimal outcomes are attained for patients undergoing immediate breast reconstruction after mastectomy.

Fat grafting during primary breast augmentation has the ability to address the limitations of soft tissue coverage of breast implants. The purpose of this study was to evaluate the current evidence on patient selection, surgical techniques, and assessment of outcomes with composite breast augmentation.

BACKGROUND:Oncologic outcomes with nipple-sparing mastectomy (NSM) continue to be established. We examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance (TND), in therapeutic NSMs. METHODS:Demographics, outcomes, and overall trends for all NSMs undertaken for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including TND. RESULTS:A total of 496 therapeutic NSMs were performed with average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4%) and ductal carcinoma in situ (50.4%). Sentinel lymph node sampling was performed in 79.8% of NSMs; 4.1% had positive frozen sentinel lymph node biopsies while 15.7% had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5%) followed by Stage 0 (31.3%).Per NSM, the rate of local recurrence was 1.6% (N=8); the rate of regional recurrence was 0.6% (N=3). In all, 171 NSMs had magnetic resonance imaging available to assess tumor-to-nipple distance (TND). NSMs with TND ≤1 centimeter (25.0% versus 2.4%, p=0.0031/p=0.1129) and ≤2 centimeters (8.7% versus 2.0%; p=0.0218/p=0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, TND ≤1 centimeter was the only significant risk factor for recurrence (OR=13.5833, p=0.0385). No factors were significant in regression analysis. CONCLUSIONS:In this group of early stage and in situ breast carcinoma, therapeutic NSM appears oncologically safe with a locoregional recurrence rate of 2.0%. Tumor-to-nipple distances of ≤1 centimeter and ≤2 centimeters trended to higher rates of recurrence.

Background/UNASSIGNED:Mastectomy flap and nipple-areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated. Methods/UNASSIGNED:All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed. Results/UNASSIGNED:= 0.0494). Conclusions/UNASSIGNED:NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. SUMMARY/CONCLUSIONS:Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.

Nipple-sparing mastectomy (NSM) places greater stress on the breast-skin envelope compared with traditional mastectomy techniques. Precise mastectomy flap dissection is critical to optimize breast skin flap thickness and minimize complication risk. This study evaluated patient-specific factors associated with mastectomy flap quality to improve technical success in NSM. Ideal NSM flap thickness was determined for all NSMs from 2006 to 2016 with available preoperative breast magnetic resonance imaging (MRIs). Demographic, operative variables, and flap thickness were compared for NSMs as stratified by body mass index (BMI) and mastectomy weight. Of the 1,037 NSMs, 420 cases (40.5%; 243 patients) had MRI data available, which included 379 (36.5%) preoperative breast MRIs. Average BMI was 24.08 kg/m², whereas average mastectomy weight was 442.28 g. NSMs were classified according to BMI <25 kg/m², 25-30 kg/m², and >30 kg/m². Average ideal overall NSM flap thicknesses in these groups were 10.43, 12.54, and 14.91 mm, respectively. Each incremental increase in average overall NSM flap thickness per BMI category was statistically significant (P < 0.0001; P < 0.0001; P = 0.0002). NSMs were also classified into mastectomy weight categories: <400 g, 400-799 g, and ≥800 g. Average overall NSM flap thicknesses in these groups were 9.97, 12.21, and 14.50 mm, respectively. Each incremental increase in average overall NSM flap thickness per mastectomy weight category was similarly statistically significant (P < 0.0001; P < 0.0001; P < 0.0001). NSM flap thickness and quality is related to BMI and breast size. Characterizing these anatomic variations preoperatively will help surgeons optimize mastectomy flap dissections and minimize ischemic complications in breast reconstruction after NSM.

BACKGROUND:Nipple-sparing mastectomy (NSM) allows for preservation of the entire nipple-areola complex utilizing various incision patterns. Reconstructive trends and overall risk associated with these diverse NSM incisions have yet to be fully elucidated. METHODS:All NSMs from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar. RESULTS:A total of 1212 NSMs were performed with 1207 NSMs included for final analysis. Of these, 638 (52.9%) utilized an inframammary fold incision, 294 (24.4%) utilized a lateral radial incision, 161 (13.3%) used a vertical radial incision, 60 (5.0) utilized a Wise pattern incision, 35 (2.9%) used a previous incision, and 19 (1.6%) utilized a periareolar incision.The groups were heterogeneous and differed significantly with regards to various factors including age (p<0.001), body-mass index (p<0.001), mastectomy indication (p<0.001), mastectomy laterality (p<0.001), pathologic cancer stage (p<0.001), reconstruction modality (p<0.001), and adjuvant chemoradiation (p=0.031; p=0.002), among others.In crude multivariate logistic regression analysis, vertical radial (16.1%) and inframammary fold incisions (21.0%) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p=0.001) emerged as significantly protective of overall complications after controlling all variables. Wise pattern incisions increased the odds of complications, although not quite significantly (p=0.051). CONCLUSIONS:NSM may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with lowest complications while Wise pattern incisions may increase risk.