Mastectomy Incision Research Articles

Mastectomy Incision Choice in Ptotic Patients Undergoing Immediate Implant-Based Reconstruction: A Comparison of Wise-Pattern and Oblique-Elliptical Incisions.

Breast ptosis presents challenges for implant-based reconstruction due to the large skin envelope. Skin-reducing mastectomy reduces the envelope but must consider many other factors including complications. Limited data exist on incision impact on outcomes. We compare oblique-elliptical and Wise-pattern incisions on complications and patient-reported quality of life in immediate implant-based reconstruction.A retrospective review of patients who underwent immediate implant-based skin-reducing mastectomy at a single institution from 2015 to 2021 was done and was divided into two cohorts: wise and oblique incisions. Demographics, complications, and patient-reported outcomes (BREAST-Q) were compared. Descriptive, t test, and chi-square test analyses, followed by adjusted linear and logistic regression models, were performed to compare complication rates and BREAST-Q scores.Eighty-nine patient breasts were analyzed, 39 (43.8%) in the oblique (OI) and 50 (56.2%) in the wise (WI) cohort. No differences in demographics or preoperative comorbidities between groups were found. The oblique incision patients had significantly more mean total complications (OI 1.46 vs WI 0.88; P = 0.048), as well as increased incidence of explantation (OI 15 vs WI 3; P = 0.003) and cellulitis (OI 14 vs WI 3; P = 0.020) compared to wise group. Linear regression analysis revealed that incision choice was a significant predictor of complication rate (β = -1.06, 95% CI [-1.63--0.50], P = <0.001). Logistic regression analysis showed that incision was a significant predictor of specific complications such as explantation (odds ratio = 0.10, 95% CI [0.02-0.52], P = 0.006) and cellulitis (odds ratio = 0.16, 95% CI [0.03-0.73], P = 0.018), with decreased risk of choosing wise incision. There was no difference in BREAST-Q results.Ptotic patients with oblique incision are associated with higher rates of postoperative complications compared to wise incisions.These findings suggest that incision choice is an important factor in postoperative complication development and emphasizes the need for further investigation and discussion with patients during preoperative planning.

Prospective Sensory Outcomes for Targeted Nipple Areola Complex Reinnervation (TNR) in Gender-Affirming Double Incision Mastectomy with Free Nipple Grafting.

This study analyses the anatomy and sensory outcomes of targeted nipple areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting (FNG). TNR is a novel technique to preserve and reconstruct intercostal nerves (ICN) to improve postoperative sensation. There is little evidence on relevant anatomy and outcomes. 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed preoperatively, and at one, three, six, nine and twelve months postoperatively. 50 mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P >0.05). BMI ≥30kg/m 2 and mastectomy weight ≥800g were associated with significantly worse preoperative sensation ( P <0.05). Compared to preoperative values, NAC sensation was worse at 1 month ( P <0.01), comparable at 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only ( P <0.05), and with direct coaptation of ≥2 branches compared to direct coaptation of a single branch ( P <0.05). All patients reported return of nipple and chest sensation at one year postoperatively and 88% reported return of some degree of erogenous sensation. TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. Use of multiple ICN branches and direct coaptation led to the best sensory outcomes.

How to Do a US-guided Preoperative Planning to Choose the Proper Location for Mastectomy Incision (with video).

video width="640" height="480" controls controlsList="nodownload" poster="https://www.revistachirurgia.ro/pdfs/video/anna_scarabosio_vascular_mapping.jpg" style="margin-top: -20px;" source src="https://www.revistachirurgia.ro/pdfs/video/anna_scarabosio_vascular_mapping.mp4" type="video/mp4" Your browser does not support the video tag. /video Mastectomy remains a prevalent procedure in oncologic surgery, driven by the high incidence of breast cancer and the crucial role of surgical intervention. Over the last two decades, mastectomy techniques have significantly evolved, with conservative approaches such as skin-sparing and nipple-sparing mastectomies gaining widespread adoption. This shift aligns with patients' contemporary demands for improved aesthetic outcomes and quality of life. Concurrently, reconstructive techniques, particularly the pre-pectoral approach, have advanced, focusing on reducing complications like cutaneous necrosis while optimizing cosmetic results. Our study emphasizes the importance of preoperative vascular mapping using Ultrasound Doppler to identify key blood vessels supplying the breast skin and nipple. This technique allows for precise incision placement, preserving vital vessels and minimizing the risk of necrosis. The results demonstrate that US-guided preoperative mapping is a cost-effective method that enhances surgical outcomes and patient satisfaction in breast reconstruction following mastectomy.

Proton Therapy in the Treatment of Men with Breast Cancer

PurposeMale breast cancer treatment involves multimodality therapy, including radiation therapy; nevertheless, few men have received proton therapy (PT) for it. Further, heart disease is an established leading cause of death in men, and radiation therapy heart dose correlates with cardiac toxicity, highlighting the need for cardiac-sparing radiation techniques. Thus, we provide a descriptive analysis of PT in a male breast cancer cohort. Patients and MethodsMen who received PT for localized breast cancer between 2012 and 2022 were identified from a prospective database. Toxicities were prospectively recorded by using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. ResultsFive male patients were identified. All had estrogen receptor (ER)–positive, Her2neu-negative disease and received adjuvant endocrine therapy. One had genetic testing positive for BRCA2, one had a variant of unknown significance (VUS) in the APC gene, and one had a VUS in MSH2. Median age was 73 years (range, 41–80). Baseline comorbidities included obesity (n = 1), diabetes (n = 1), hypertension (n = 4), history of deep vein thrombosis (n = 1), personal history of myocardial infarction (n = 3; 1 with a pacemaker), and a history of lung cancer (n = 1). All received PT to the left chest wall and comprehensive regional lymphatics. One received passive-scattering PT, and 4 received pencil beam scanning. One patient received a boost to the mastectomy incision via electrons. Median heart dose was 1 GyRBE (range, 0–1.0), median 0.1-cm3 dose to the left anterior descending artery was 7.5 GyRBE (range, 0–14.2), and median follow-up was 2 years (range, 0.75–6.5); no patient experienced a new cardiac event, and all remain free from breast cancer recurrence and progression. ConclusionIn a small case series for a rare diagnosis, PT to the chest wall and regional lymphatics, including internal mammary nodes, resulted in low cardiac exposure, high local regional disease control rates, and minimal toxicity. Proton therapy should be considered for treating men with breast cancer to achieve cardiac sparing.

Intraoperative Anatomy and Postoperative Sensation of Targeted Nipple Areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy with Free Nipple Grafting

Intraoperative Anatomy and Postoperative Sensation of Targeted Nipple Areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy with Free Nipple Grafting

Head-to-Head Analysis of Vertical vs Horizontal Incision Patterns in Breast Reconstruction: Surgical Outcomes and Aesthetic Implications.

Modern aesthetically optimized breast reconstruction requires collaboration between the patient, breast surgeon, and plastic surgeon. To optimize both surgical outcome and aesthetic results, incision patterns must be carefully planned. We aimed to determine whether vertical or horizontal orientation of mastectomy incision was preferred in the general population and to analyze corresponding complication profiles. A retrospective review was performed of all patients undergoing bilateral mastectomy followed by autologous breast reconstruction utilizing either vertical or horizontal incision from January 2011 to November 2022. Postoperative complications of the 2 incision patterns were analyzed. Additionally, crowdsourcing was utilized to assess aesthetic implications of horizontal and vertical incision patterns on postoperative pictures of completed breast reconstruction. Survey rater demographics were also analyzed to assess differences in scoring based on voter characteristics. There were no significant differences in postoperative breast complications between patients with horizontal or vertical incisions when considering wound, infection, seroma, hematoma, fat necrosis, or overall complications (P > .05). Crowdsourcing showed that, regardless of voter demographics, vertical incisions were preferred over horizontal incisions (P < .001). Additionally, voters who knew someone who had undergone breast reconstruction were more likely to rate all incision patterns higher than other voters (P < .001). Although there are no significant differences in complication profiles between vertical and horizontal incisions in autologous breast reconstruction patients, vertical incision patterns are preferred aesthetically by the general population.

Assessment of the lipodermal flap for avoidance of lateral dog-ear deformity in mastectomy

BackgroundPatients who are at an elevated risk of developing lateral dog ears deformity following mastectomy, such as those who have high body mass index, or who have too much tissue in the lateral chest wall, and who are not ideal candidates for immediate reconstruction or the Goldilocks mastectomy, should have a lateral dog-ear assessment and should consider the lipodermal flap technique. The purpose of this study was to explain a modification to the mastectomy incision known as the lipodermal flap procedure that avoids this deformity and improve patient satisfaction and quality of life.MethodsThis study included 50 female breast cancer patients who were recommended for a modified radical mastectomy (MRM); they had large cup-size breasts and were expected to develop a dog-ear deformity after the mastectomy.ResultsThe type of mastectomy was MRM in 48 patients, and palliative toilet mastectomy in only two patients. The operative time median is about 1.5 h (1.5–1.5), the wound length median is about 20 cm (19–20), and the blood loss median is about 200cc (180–220). Scar discomfort: 45 patients (90%) did not experience scar discomfort, and five patients (10%) felt scar discomfort. Regarding wound dehiscence, 46 patients had no wound dehiscence and four patients (8%) had wound dehiscence and 48 patients (96%) had no flap necrosis and 2 patients (4%) had flap necrosis. Cosmetic result: 4 patients (8%) with wound cosmesis were not accepted and 46 (92%) patients were accepted; 46 (92%) patients were satisfied; 100% of the cases had no dog ear in the lateral part of the mastectomy scar.ConclusionsThe lipodermal flap technique is safe, feasible, and reliable and could be applied during MRM once lateral dog-ear deformity is anticipated with a high satisfaction rate and lower incidence of wound complication.

Creating a context for recipient vessel selection in deep inferior epigastric perforator flap breast reconstruction

In autologous tissue breast reconstruction, recipient vessels are important for artery perfusion and venous drainage to ensure free flap survival. There are insufficient clinical outcomes to select efficient recipient vessels in bi-pedicled deep inferior epigastric perforator (DIEP) flap reconstruction. We presented a retrospective observational series of 108 patients regarding the diameter, anastomosis time, and re-anastomosis rate in internal mammary (IM), circumflex scapular (CS), thoracodorsal (TD), thoracoacromial (TA), lateral thoracic (LT), and internal mammary perforator (IMP) vessels of bi-pedicled DIEP flaps for breast reconstruction after mastectomy. The outcomes were the vessel re-anastomosis rate, flap failure rate, vessel anastomosis time, and complications. Data were gleaned from the chi-square test, Fisher's test, and analysis of variance using Scheffe's test as a post hoc analysis. The level of significance was p<0.05. There were no significant differences in the diameters of the artery, first vein, and second vein across the recipient vessels (p>0.05). However, the anastomosis time was longer in IM and TA than in CS, TD, and LT (p<0.001). Also, there were no significant differences for re-anastomosis, flap necrosis, and fat necrosis among different recipient vessels (p>0.05). Because of the altered mastectomy incisions, this study provides complete anatomical vascular properties and suggests that altering recipient vessel selection for bi-pedicled DIEP flaps can shorten anastomosis time and better conceal scars.

Wise Pattern versus Transverse Pattern Mastectomy in Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

The Wise pattern adapted to mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. The authors compared the time for exchange, time to initiate postmastectomy radiotherapy, and complication rates between Wise pattern and transverse incision pattern reconstructions. Records of patients who underwent immediate, two-stage, implant-based breast reconstruction (IBBR) between January of 2011 and December of 2020 were retrospectively reviewed. Two cohorts were compared according to the incision pattern: Wise pattern versus transverse incision pattern. Complications were compared after propensity score matching. The authors initially analyzed 393 two-stage immediate IBBRs in 239 patients [91 IBBRs (23.2%) in the Wise pattern group and 302 (76.8%) in the transverse pattern group]. Expansion time (53 days versus 50 days, P = 0.9), time for tissue expander-to-implant exchange (154 versus 175 days, P = 0.547), and time to initiate postmastectomy radiotherapy (144 days versus 126 days, P = 0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, P < 0.001) and the 30-day rate of wound complications requiring excision/débridement and closure procedures (20% versus 7%, P < 0.001) were significantly higher in the Wise pattern group. After propensity score matching, the 30-day rate of wound complications was persistently higher (25% versus 10%, P = 0.03) in the Wise pattern group. The Wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed tissue expander placement may improve the safety profile of this procedure. Therapeutic, III.

61. Wise-pattern Versus Transverse Pattern Mastectomy in Two-stage Implant-Based Breast Reconstruction: A Propensity Score-matched Analysis

PURPOSE: The wise pattern adapted to the mastectomy incisions has become a valuable asset for breast reconstruction in patients with large and ptotic breasts. Herein, we compared the time for exchange, time to initiate postmastectomy radiotherapy (PMRT) and complications rate between reconstructions performed with wise pattern versus a transverse incision pattern. METHODS: We retrospectively reviewed the record of patients who underwent immediate two-stage implant-based reconstruction (IBBR) between January 2011 and December 2020. Two cohorts were compared according to the incision pattern: wise versus transverse incision pattern. Complications were compared after propensity score matching. RESULTS: We initially analyzed 393 two-stage immediate IBBR in 239 patients, 91 (23.2%) in the wise-pattern group and 302 (76.8%) in the transverse pattern group. The expansion time (53 days versus 50 days, p=0.9), the time for TE-to-implant exchange (154 versus 175 days, p=0.547), and the time to initiate PMRT (144 days versus 126 days, p=0.616) were not different between groups. Before propensity score matching, the 30-day rate of wound-related complications (32% versus 10%, p<.001) and 30-day rate of wound complications requiring E/D+C procedures (20% versus 7%, p<.001) were significantly higher in the wise-pattern group. After propensity score matching, the 30-day rate of wound-related complications persisted significantly higher (25% versus 10%, p=0.03) in the wise-pattern group. CONCLUSION: The wise pattern mastectomy independently increases the incidence of wound-related complications versus only transverse patterns during two-stage IBBR, even after propensity score matching. Delayed TE placement may improve the safety profile of this procedure.

D120. Prospective Cohort Study Evaluating Chest Reinnervation in Gender Affirming Double Incision Mastectomy with Free Nipple Grafting

D120. Prospective Cohort Study Evaluating Chest Reinnervation in Gender Affirming Double Incision Mastectomy with Free Nipple Grafting

D22. Effects of Exogenous Testosterone on Scarring in Gender-affirming Chest Surgery

PURPOSE: Chest masculinization surgery (CMS) can lead to hypertrophic scarring with reduced quality-of-life and need for revision. Given our clinical observations and prior animal studies suggesting testosterone(T) has negative effects on wound healing, we hypothesized T is associated with worse scarring after CMS. METHODS: 152 patients undergoing either double incision mastectomy or keyhole/circumareolar mastectomy were enrolled in an IRB-approved prospective registry at JHU from 2017-2022. Data regarding patient demographics, hormone regimen, scarring co-morbidities, procedural details and complications were collected. Scars were assessed by four blinded clinicians using Manchester Scar Scale and SCARS-scale using photos taken at early, mid, and late post-op timepoints. T-tests and Pearson correlations were used to look for association between scarring and T dose/level. RESULTS: 66% of patients were white and 90% were on T. MSS contour and SCAR palpability were positively correlated with increasing weekly dose of T (r=0.2/p=0.034 and r=0.234/p=0.013,respectively). Patients with high preop T-level (>500ng/dl) and high weekly T-dose (>50ng/dl) had a higher mean score on SCAR palpability subscale and SCAR overall impression subscale compared to patients in low preop T (<500ng/dl) and low weekly T-dose (<50ng/dl) group (p=0.038,p=0.047). CONCLUSION: Exogenous testosterone appears to be correlated with hypertrophic scarring after CMS. Current T-dosing regimens focus largely on subjective patient response and may lead to supratherapeutic doses. Recent trends towards continuation of hormones throughout perioperative period may warrant further evaluation of risks and benefits.

Postmastectomy Immediate Implant-Based Breast Reconstruction with Scarless Latissimus Dorsi Flap-a Simple and Versatile Technique.

In low- and middle-income countries, breast reconstruction is not widely practiced due to a lack of specialized equipment, skilled personnel, and high costs. The scarless latissimus dorsi flap is a useful technique which can harvest a major portion of the latissimus dorsi muscle using the same mastectomy incision without requiring repositioning of the patient, to cover the lower pole of prosthesis for reconstruction. The aim of this study was to assess and evaluate the cosmetic results and complications of scarless LD flap used as a lower pole cover in post-mastectomy breast reconstruction with implants. This is a pilot study of 18 breast cancer patients who underwent implant-based scarless LD flap breast reconstructions during a period of 4years from 2017 to 2021. A questionnaire based on relevant subscales of BREAST-Q scores was completed by all the patients and used for evaluation. A total of 18 patients who underwent 20 surgeries were evaluated for the study. The median age was 44.5years. The mean operative time was observed to be 164.50min. The mean length of hospital stay was 3.1days. From the Breast Q subscales, the mean cosmetic score was 31 out of 36 (range 27-36) (higher score reflecting better cosmetic outcome), and the mean physical well-being score was 17.25 out of 54 (range 12-29) (lower score reflecting better outcome). Overall complications were observed to be 20% which included minimal flap necrosis in 2 patients which was managed conservatively, and seromas in 2 patients which needed ultrasound-guided aspirations twice. There were no major complications. The scarless LD flap provides an adequate lower pole muscle coverage for implants in breast reconstruction. It has less morbidity and good cosmetic outcomes. It is time and cost-effective, requires no patient repositioning, and uses standard breast instruments.

Mastectomy is a safe procedure in transgender men with a history of breast reduction

Little is known about the safety and surgical outcomes of mastectomy after breast reduction in the trans male population. Several concerns have been voiced that performing mastectomy with prior breast reduction surgery, increases the risk for complications and revision surgery. All transgender men with a history of breast reduction, who underwent a mastectomy at our center between 01-1990 and 01-2021 were identified from our hospital registry. A retrospective chart study was conducted recording surgical characteristics, surgical complications, revision surgery, and clinical follow-up. A total of 1362 subcutaneous mastectomies were performed between 01-1990 and 01-2021. A total of 36 (2.6%) individuals were included (35 bilateral and 1 unilateral breast reduction). The mean age at mastectomy was 37 ± 10 years, and the median time between breast reduction and mastectomy was 6.3 years (range 1.0–31.1). Most individuals underwent a Wise-pattern breast reduction (91%) and a double incision mastectomy with free nipple grafts (86%). Following mastectomy, one acute reoperation was performed because of hemorrhage (3%). Partial pedicled nipple necrosis was seen in 7% and (partial) non-take of nipple grafts in 4%. Scar revisions were performed in 9%, dogear corrections in 20%, and both nipple corrections, and contour corrections in 6%. When comparing the outcomes in literature for surgical complications, scar revision, contour correction or nipple areolar complex revision, no clear disadvantage seems to be present when performing mastectomy after breast reduction. Mastectomy is a safe procedure in transgender men with a history of breast reduction.

Nerve-Preserving Superomedial Pedicle Breast Reduction Approach for Chest Wall Masculinization: A Case Report

Introduction: Gender affirming chest surgeries are a treatment for transgender and gender diverse individuals who suffer from gender dysphoria. Double incision mastectomy with free nipple grafts is the most common technique used for masculinization of the chest for Fischer grade 2B to 4 patients. However, this technique sacrifices the nerves to the nipple-areolar complex (NAC). While multiple nipple pedicles have been described in cisgender reduction mammoplasty, only an inferior pedicled mammaplasty approach has been described for chest wall masculinization for Fischer grade 2B to 4 patients. Case Presentation: We describe the surgical technique of a superomedial pedicle chest masculinization surgery for an individual with Fischer grade 2B breasts. Sensation was preserved at 2-weeks post-surgery. At 4-months, using a 0 to 10 numeric rating scale, patient satisfaction was 9 for the overall cosmetic outcome and a 9 for the masculinization. Using inferior sternum sensation as a reference (10), areola sensation on the superior side adjacent the nipple was a 6.5 on the right and an 8 on the left. Chest sensation was a 10 in the superolateral, inferolateral, and superomedial quadrants bilaterally, and was an 8 in bilateral inferomedial quadrants. 2-point discrimination of the areola was assessed on the inferior side adjacent the nipple and was 13mm on the left and 14mm on the right. Semmes-Weinstein monofilament testing of the areola was performed adjacent to the nipple superiorly (R: 4.31, L: 4.56), inferiorly (R: 4.31, L: 6.65), medially (R: 4.31, L: 6.65), and laterally (R: 4.31, L: 6.65). Conclusion: A mastectomy technique using a superomedial pedicle can preserve the nerve to the nipple-areolar complex to retain sensation while providing sufficient cosmetic outcome.

Anterior-First Approach for Latissimus Dorsi Myocutaneous Flap Breast Reconstruction: A Refined Elevation Method with Detailed Video Instructions.

The latissimus dorsi myocutaneous (LDMC) flap is a preferred flap in breast reconstruction for its wide surface area and volume. Since the flap is situated in the midback area, a lateral decubitus approach is a conventional method. However, proper visualization and access to the thoracodorsal vascular pedicle or muscle insertion is difficult from the lateral approach, causing inefficiency and surgeon fatigue. We propose the 'anterior-first' approach in LDMC flap reconstruction, where the landmark structures are first approached from the supine-anterior position through the mastectomy incision. From January 2014 to December 2020, 48 patients who received immediate breast reconstruction with LDMC flap were included in the study. Patients received reconstruction with the conventional approach (n = 20), or anterior-first approach (n = 28). Demographic factors and the operative outcomes were retrospectively analyzed and compared between the two groups. Compared to the conventional approach group, the anterior-first approach group showed improved efficiency in the duration of total reconstruction (228 versus 330 min, p &lt; 0.001), and flap elevation (139 versus 200 min, p &lt; 0.001). No difference in complication rate and time to drain removal was observed (p = 0.14 and &gt;0.9, respectively). The anterior-first approach for breast reconstruction with LDMC flap provides surgeons with an enhanced surgical exposure and superior ergonomics, leading to a safer and more efficient flap elevation.

A Single-Center 10-Year Experience of 180 Transmasculine Patients Undergoing Gender-Affirming Mastectomy While Continuing Masculinizing Hormone Replacement Therapy.

Gender-affirming mastectomy is a fundamental step in the transition process of transmasculine patients following the initiation of hormone replacement therapy. Its perioperative management, however, remains underreported and controversial. In this study, a large series of mastectomies in transmen maintaining hormonal therapy is presented. Over a 10-year study period, a consecutive series of 180 transmasculine patients undergoing chest masculinizing surgery was evaluated. Demographical and surgical data were collected and analyzed for potential factors influencing outcome. The overall rate of complications was 15.5%. Patients who underwent periareolar incision mastectomy were significantly more likely to develop any type of complication than patients with a sub-mammary incision (28.6% vs. 13.2%, p = 0.045). Hematoma was the most common reason for surgical revision. It occurred significantly more often among the periareolar group (21.4% vs. 7.9%, p = 0.041). Duration and type of hormonal therapy did not differ between patients with or without complications. In a multivariate regression analysis, smoking and type of incision were identified as significant predictors of the all-cause complication rate, whereas the influence of BMI and resection weight diminished after adjusting for confounding factors. There is scarcity of information concerning the influence of perioperative hormonal therapy in patients undergoing chest wall masculinization. The observed complication rates-with special regard to hematoma-were comparable to current reports; yet further research is needed to profoundly evaluate this topic and provide evidence-based recommendations for the perioperative management of HRT of transmasculine patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

"Hook Shape" Nipple-Sparing Mastectomy and Prepectoral Implant Reconstruction: Technique, Results and Outcomes from a Preliminary Case Series.

Nipple-sparing mastectomy (NSM) is a surgical procedure increasingly performed for breast cancer or risk reduction surgeries. The site of skin incision seems to affect not only cosmesis but also technical ease in operating and vascular viability of the nipple. We present a series of patients who underwent a modified vertical surgical approach for NSM, which resulted to be safe, reliable, and with good esthetic results. From December 2016 to February 2019, 27 "Hook Shape" incision NSMs were performed. All patients underwent an immediate subcutaneous muscle-sparing reconstruction with tissue expander covered by a titanium-coated polypropylene mesh, followed by a second surgical step with expander substitution and lipofilling on the definitive implant when indicated. Preoperative and postoperative BREAST-Q patient-reported outcomes measure was performed in all cases. Postoperative morbidity was evaluated: One patient developed seroma and another presented a systemic infection that resolved with intravenous infusion of antibiotics. One patient experienced vertical wound dehiscence, recovered after conservative treatment and without implant exposure. No implant loss was observed. Nipple-areola complex necrosis or ischemia rate was 0%. The BREAST-Q outcomes reported significant increases in the overall satisfaction with breast (p < 0.05), psychosocial well-being (p < 0.05), and sexual well-being (p < 0.05) sections. Scores in the physical impact of surgery section appeared to decline from preoperative to postoperative evaluations, with no statistically significant results. The mastectomy incision pattern can burden the surgical challenge, impact vascular viability of the nipple and significantly affect the aesthetic outcomes in breast reconstruction. We report our experience with an alternative approach for NSM, which appears a safe, practical, and reproducible method for patients with small- to medium-sized breasts and little/medium ptosis (grade I or II). This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

QS7. Acellular Dermal Matrix and Prepectoral Two-stage Breast Reconstruction: A Cohort Analysis of Alloderm, FlexHD and SurgiMend

Background: Acellular dermal matrix (ADM) is frequently used in prepectoral breast reconstruction, but few studies have examined its impact on complication risk and even fewer have examined the role of ADM type on complication risk in this patient population, leading to a non-evidence-based approach to ADM selection. The purpose of this study is to determine the risk of complications after immediate, prepectoral, tissue expander (TE) breast reconstruction based on the type of ADM used. Methods: A retrospective review of post-mastectomy breast reconstruction patients at Memorial Sloan Kettering Cancer Center from 2018-2020 was conducted. All patients had immediate, prepectoral tissue expander reconstruction with use of ADM. Both unilateral and bilateral reconstructions were included. Three types of ADM were compared: 1) Alloderm, 2) FlexHD, and 3) SurgiMend. Complication rates based on the number of tissue expanders were determined for each ADM type. Patient characteristics, including age, race, diabetes, hypertension, and smoking history, cancer treatment characteristics, including chemotherapy and radiotherapy, and surgical characteristics, including mastectomy incision type, axillary lymph node dissection, TE size, and ADM size, were also collected and compared among the three types of ADM. Unadjusted comparisons were conducted using Fisher’s exact or Kruskal-Wallis tests. Multivariate logistic regression was used to determine the impact of ADM type on complication risk after accounting for confounders. Results: Overall, 506 patients (788 TEs: 148 Alloderm, 86 FlexHD, 554 SurgiMend) were included. The three cohorts differed in terms of laterality (Unilateral: 66.7% of Alloderm, 49.1% of FlexHD, 36.1% of SurgiMend, p<0.001) and mastectomy type (Nipple-sparing: 23.4% of Alloderm, 33.3% of FlexHD, 18.9% of SurgiMend, p=0.047). SurgiMend had the highest overall complication rate (SurgiMend: 23.3%, Alloderm: 19.6%, FlexHD: 11.6%, p=0.037), but no significant differences were noted for seroma, skin flap necrosis, hematoma, infection, TE exposure, TE malposition, or TE loss. After controlling for patient, cancer treatment, and surgical characteristics, no ADM type had higher odds of overall complications or TE loss. Conclusions: In this large cohort of prepectoral reconstruction patients, we demonstrate that ADM type does not affect risk of complications. Prospective studies are warranted to evaluate ADM choice for prepectoral reconstruction in a head-to-head fashion.

Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns.

Background:Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques.Methods:Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups.Results:In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique.Conclusions:Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.