Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes

Abstract

Surgeons remain reluctant to perform nipple-sparing mastectomy (NSM) in large breasts due to a higher risk of necrosis. We performed a systematic review of the literature to evaluate indications, techniques, and outcomes in immediate or delayed breast reconstructions in large and/or ptotic breasts. The following search terms were used for both titles and key words: [NSM AND ("breast ptosis" OR "ptotic breast" OR "large breast" OR "breast hypertrophy" OR "gigantomastia")]. All forms of breast reconstruction in large and/or ptotic breasts from 1990 through September 1st 2018 reporting indications, techniques, and outcomes were included. Thirty-one studies met the inclusion criteria, yielding 1128 NSMs (709 immediate and 419 delayed) in 629 patients for analysis. The overall complication rate was 29.08%. The mastectomy flap necrosis rate was 12%, the partial nipple-areola complex (NAC) necrosis 11%, and the complete NAC rate 11%. The overall complication rate in one-stage versus delayed reconstructions was 37.52% versus 14.8%. The incidence of necrosis in one-stage versus delayed reconstructions was 5.36% versus 2.15% for partial, 5.08% versus 0.48% for complete NAC necrosis, and 4.8% versus 1.43% for skin flap necrosis. The majority of studies being small and retrospective as well as the large variation in outcomes indicates that we lack consensus on the timing of reconstruction or ideal technique. A noticeable difference in skin flap and NAC necrosis, however, is seen in the favor of NAC-delayed procedures. Randomized controlled trials are mandatory to prove this difference significantly.