Abstract
Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure
Highlights
Since obesity is an increasing phenomenon around the globe [1,2], the number of patients with large and ptotic breasts requiring surgical breast cancer treatment is consistently increasing [3]
In women with large and ptotic breasts, sparing mastectomies (SSM) and Nipple sparing mastectomies (NSM) combined with immediate breast reconstruction (IBR) have higher complication rates than staged approaches [4]
In 30 cases (48%, deep inferior epigastric perforator flaps (DIEP) n = 15, Thigh n = 15) the Internal mammary artery/vein (IMA/V) were used as recipient vessels, whereas in 32 cases (52%, DIEP n = 19, Thigh n = 13) the flaps were anastomosed to internal mammary artery perforators (IMAP) in the 2nd or 3rd intercostal spaces (ICS) (Table 1)
Summary
Since obesity is an increasing phenomenon around the globe [1,2], the number of patients with large and ptotic breasts requiring surgical breast cancer treatment is consistently increasing [3]. In women with large and ptotic breasts, SSM and NSM combined with immediate breast reconstruction (IBR) have higher complication rates than staged approaches [4]. Delayed and staged techniques, cannot be applied to all cases, for acute breast cancer requiring timely mastectomy. Since impaired wound healing and skin complications after autologous IBR can significantly reduce quality of life and considerably prolong recovery time, delaying urgent adjuvant therapy, it potentially hampers oncological outcomes [5]. We aimed to identify potential risk factors predicting skin complications in patients with large and ptotic breast, who underwent simultaneous autologous IBR after wise pattern SSM and NSM. This study offers selection criteria for suitable patients, a better understanding of the risk factors contributing to post-operative complications, and provides guidance for improved care
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