Mastectomy Flap Necrosis Research Articles

Direct-to-implant single-stage immediate breast reconstruction with acellular dermal matrix: predictors of failure.

Direct-to-implant single-stage immediate breast reconstruction using acellular dermal matrix is a cost-effective alternative to two-stage expander-implant reconstruction. The purpose of this study was to identify predictors of direct-to-implant single-stage immediate breast reconstruction failure, defined as need for early (≤6 months) revision surgery. The authors conducted a retrospective cohort study of all patients with direct-to-implant single-stage immediate breast reconstruction in 2010 and 2011 at three University of British Columbia hospitals. Data were compared between successful and failed single-stage reconstructions. Predictors of failure were identified using multivariate logistic regression. Patient demographics and complications were compared to a random sample of control patients with two-stage alloplastic reconstruction without acellular dermal matrix. Of 164 breasts that underwent direct-to-implant single-stage immediate breast reconstruction, 52 (31.7 percent) required early revision. Increasing breast cup size was the only significant predictor of early revision compared with bra size A (OR for bra size B, 4.86; C, 4.96; D, 6.01; p < 0.05). Prophylactic mastectomies showed a trend toward successful single stage (OR, 0.47; p = 0.061), whereas smoking history trended toward failure (OR, 1.79; p = 0.065). Mastectomy flap necrosis was significantly higher in direct-to-implant single-stage immediate reconstruction cases compared to two-stage controls. Direct-to-implant breast reconstruction can be reliably performed in a single stage in patients with small breast size. Increasing breast cup size confers a higher chance of early revision. A two-stage approach may be more cost-effective in larger breasted patients. Risk, III.

Skin-sparing mastectomy and immediate tissue expander breast reconstruction in patients with macromastia using the Passot breast reduction pattern.

Skin-sparing mastectomy (SSM) with immediate tissue expander reconstruction poses a challenge in the patient with macromastia or excessive ptosis. Skin reduction via the Wise pattern has been described but is associated with high rates of skin necrosis. The study group consisted of 43 women with grade 2 or 3 ptosis who underwent SSM and immediate reconstruction with tissue expanders, using the Passot (horizontal) skin reduction pattern. Age ranged from 31 to 67 years (mean, 51 years). The endpoints measured were time to final expansion, mastectomy skin flap necrosis, infectious complications, and total complications. Thirty reconstructions were bilateral and 13 were unilateral (73 breasts total). Follow-up ranged from 6 to 55 months (mean, 20). Common comorbid conditions included hypertension (n = 16), obesity (n = 22), and smoking (n = 9). The mean body mass index was 30.6 (range, 19.4-58.6). Twenty-one patients underwent chemotherapy; 12 received radiation. The mean initial fill was 196 mL (range, 0-420 mL), and the mean time to final expansion was 84 days (range, 28-225 days). Five patients did not complete the reconstruction, 2 because of cancer recurrence and 3 because of infection. There were 3 cases of mastectomy flap necrosis occurring after tissue expander placement (7%). There were 7 infectious complications (16%). The use of a horizontal breast reduction pattern at the time of expander placement produces consistently good esthetic outcomes and a low rate of skin necrosis, and it should be considered as an option in patients with macromastia or ptosis undergoing SSM and immediate reconstruction.

Risk factors for mastectomy flap necrosis following immediate tissue expander breast reconstruction

Tissue expander placement is a mainstay of reconstructive surgery in the post-mastectomy patient. Necrosis of the native breast tissue is one of the most significant concerns in their post-operative care. The goal of this study is to elucidate factors that confer risk of this outcome. Chart review was conducted for a consecutive series of immediate tissue expander reconstructions by the two senior authors. Data was collected for several preoperative and intraoperative variables, as well as the outcome of mastectomy flap necrosis. Of the 1566 breasts that were examined, 135 (8.6%) experienced flap necrosis. The cohorts with and without flap necrosis were well matched. Those with the outcome of interest had significantly higher rates of switching to an autologous method of reconstruction (31.9% vs 6.2%, p < 0.001). Regression analysis revealed smoking status, increased age, tumescent mastectomy technique, and high (>66.67%) intraoperative tissue expander fill to confer increased risk of mastectomy flap necrosis. While smoking and older age are well-supported by the literature, tumescent technique and tissue expander fill are more novel points of discussion, which may serve as proxies for other issues. Awareness of these risk factors and their interplay will aid in clinical judgement and postoperative care of these patients.

The ability of intra-operative perfusion mapping with laser-assisted indocyanine green angiography to predict mastectomy flap necrosis in breast reconstruction: A prospective trial

Mastectomy skin flap ischaemia leading to necrosis is a common occurrence. Laser-assisted indocyanine green (ICG) angiography can assist to locate these poorly perfused areas intra-operatively. Our study aims to identify specific perfusion values produced by ICG angiography that accurately predict mastectomy flap necrosis. A total of 42 patients undergoing autologous or implant-based breast reconstruction had mastectomy flaps imaged using laser-assisted ICG angiography at the completion of reconstruction. Intra-operative perfusion values were correlated with postoperative skin flap outcomes. Risk factors for abnormal perfusion were recorded and analysed. A total of 62 breast reconstructions were imaged, including 48 tissue expander reconstructions, six transverse rectus abdominis myocutaneous (TRAM) flaps, six deep inferior epigastric perforator (DIEP) flaps and two direct-to-implant reconstructions. Eight cases (13%) of full-thickness skin necrosis were identified postoperatively. A SPY Elite(®) value of ≤ 7 accurately predicted the development of flap necrosis at 88% sensitivity and 83% specificity. False-positive cases (those with perfusion values ≤ 7 which did not develop necrosis) were more likely to have a smoking history and/or to have had an epinephrine-containing tumescent solution used during mastectomy. Excluding patients with smoking or epinephrine use, a SPY value of ≤ 7 predicted flap necrosis with a sensitivity of 83% and specificity of 97%. Thus, these data suggest that laser-assisted ICG angiography predicts postoperative outcomes with high accuracy. In our series, a SPY value of ≤ 7 correlated well with mastectomy flap necrosis. Furthermore, smoking and intra-operative injections containing epinephrine should be considered when evaluating low perfusion values as they can lead to false-positive test results.

Tumescent Technique Does Not Increase the Risk of Complication Following Mastectomy with Immediate Reconstruction

Despite the growing interest in the advantages of tumescent mastectomy technique, there remain concerns that tumescent solution may increase postoperative complication rates. This study evaluates patient outcomes following tumescent mastectomy in the setting of immediate prosthetic reconstruction. Retrospective review of 1,491 breasts (1,030 patients) treated by 4 oncologic and 2 reconstructive surgeons between 2004 and 2012 at a single institution. The primary outcomes of interest included seroma, hematoma, infection, and mastectomy flap necrosis, as well as conversion to autologous reconstruction. Multiple logistic regression was used to determine the adjusted influence of tumescence on outcomes. The tumescent cohort (n = 890 breasts) was younger and experienced lower rates of preoperative radiation than the nontumescent cohort (n = 601 breasts). Mean follow-up was 21.2 months. While tumescent procedures were on average 20 min faster, postoperative complication rates did not significantly differ between cohorts. Regression analysis controlling for potential confounders, including differences in surgeon technique, failed to identify tumescent mastectomy as an independent risk factor for complication [odds ratio (OR) = 1.2, 95% confidence interval (CI) = 0.8-1.8, p = 0.385]. Individually, neither seroma, hematoma, infection, nor flap necrosis was affected significantly by the use of tumescence (OR = 1.66, 95% CI = 0.73-3.78, p = 0.229; OR = 1.11, 95% CI = 0.42-2.95, p = 0.837; OR = 0.84, 95% CI = 0.4-1.75, p = 0.689; OR = 1.19, 95% CI = 0.7-2.03, p = 0.67, respectively). This longitudinal study is well equipped to assess the influence of tumescent mastectomy technique in the hands of experienced and high-volume oncologic surgeons on postoperative outcomes. Our analysis suggests that in the setting of an immediate prosthetic reconstruction, tumescent mastectomy does not independently affect postoperative complication rates.

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

INTRODUCTION: Nipple-sparing mastectomy has gained popularity, but the question remains whether it can be offered safely to women with prior history of reduction mammaplasty or mastopexy. Presented is our updated experience with offering nipple-sparing mastectomy to this patient population. METHODS: Patients at our institution who had reduction mammaplasty or mastopexy prior to nipple-sparing mastectomy were identified and their records reviewed. Outcomes measured include nipple-areolar complex viability, mastectomy flap necrosis, infection, cancer in the nipple-areolar complex and breast cancer recurrence. RESULTS: The records of our nipple-sparing mastectomy patients from 2006 through 2012 were reviewed. We present eleven patients (n=19 breasts) who underwent nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Seventeen breasts had reduction mammaplasties while the remaining two had mastopexies. In all cases, reduction mammaplasty or mastopexy were in the patient’s surgical history and not performed as part of a planned two stage nipple-sparing mastectomy procedure. The mean age of the patients was 47.5 and the mean BMI was 27.6. None of the patients in this subset were diabetic, and one patient was a smoker. Twelve breasts had therapeutic resections, and seven were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 104.3 months (range, 33 days to 40 years). Fourteen patients were reconstructed immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and four with immediate transverse rectus abdominis myocutaneous free flaps. Prior reduction mammaplasty or mastopexy incisions were used in all cases. Complications included one hematoma requiring evacuation, one breast with mastectomy flap necrosis, and one displaced implant requiring revision. There were no positive subareolar biopsies. Nipple viability complications included a partial necrosis rate of 15.8% (3/19). Mean follow-up time was 14.5 months. CONCLUSION: Our updated experience demonstrates that the outcomes of nipple-sparing mastectomy in patients with a history of reduction mammaplasty or mastopexy are comparable to the standards for patients who undergo nipple-sparing mastectomy alone.

Plastic Surgery and Smoking

Sir: We read with great interest your publication entitled “Plastic Surgery and Smoking: A Prospective Analysis of Incidence, Compliance, and Complications” by Coon et al. (Plast Reconstr Surg. 2013;131:385–391). We agree with the authors that a methodologic approach to the detection and management of patients using tobacco products can help to optimize outcomes. Smoking is one of the leading risk factors for all diseases worldwide and damages the body irreversibly when patients smoke for many years; patient smoking status affects many aspects of plastic surgery, including patient selection, counseling, management, and outcomes.1 Smoking has negative effects on the cardiovascular, pulmonary, mucous membranes, skin, and muscles.2 The skin of a smoker appears yellowish (with poor tissue under epidermis) and dehydrated, and in most cases with postoperative scars that are not as good. As the authors stated in the article, necrosis is a complication that is created in most patients who are heavy smokers, and generally represents one of the most uncomfortable complications in plastic surgery. But how should these complications be prevented? As doctors, we care about patients’ health and therefore discourage smoking. Patients who are strongly motivated to undergo cosmetic surgery, particularly women, have found a weapon with this strong motivation to help them resist smoking. Knobloch et al.3 affirmed that 4 weeks of abstinence from smoking reduces smoking-associated complications, and Chang et al.4 affirmed that, in patients undergoing free transverse rectus abdominis musculocutaneous flap breast reconstruction, smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery. However, according to our practical experience, we advise patients that ceasing smoking 6 weeks before surgery dramatically improves the postoperative period and decreases the incidence of complications, and 6 months is not long enough to define a patient as nonsmoking. When the medical history of the patient is being obtained at the time of hospitalization for surgery, the important questions are, “Do you smoke? How many cigarettes a day? For how many years?” The answers to these questions can justify alterations in hematology, or data may affect the choice of intervention to implement. According to the World Health Organization, a smoker can no longer be considered as such after 5 years of smoking cessation. For example, mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction.5 Breast reconstruction should be performed with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Patients who wish to undergo plastic surgery are also highly motivated to have a postoperative course without complications, and then decide to stop smoking in the preoperative period. Only a few of them are able to totally eliminate their dependence on smoking. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mauro Barone, M.D. Annalisa Cogliandro, M.D. Paolo Persichetti, M.D., Ph.D. Plastic, Reconstructive, and Aesthetic Surgery Unit Campus Bio-Medico University of Rome Rome, Italy

Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy?

There has been an increase in the use of nipple-sparing mastectomy (NSM) with immediate breast reconstruction for the treatment of early-stage breast cancer patients. Mastectomy flap complication including nipple loss is a major concern and usually associated with the surgical technique. The authors evaluated potential risk factors of mastectomy flap complications, especially focussing on the impact of reconstructive variables. Using a prospectively collected database, we reviewed 130 cases of NSM between January 2009 and December 2012. Only cases using lateral incision were included. Potential patient- and procedure-related risk factors were analysed using logistic regression analysis to investigate associations with the development of mastectomy flap necrosis. Among the 130 cases, 70 underwent autologous tissue reconstruction and 60 underwent two-stage prosthesis reconstruction using a tissue expander. All patient- and procedure-related characteristics were similar between the two groups. Mastectomy flap complications occurred in 21 cases (16.2%), including total nipple necrosis in 5 (3.8%) and mastectomy flap necrosis in 10 (7.7%). The autologous tissue group showed a significantly lower rate of complications than the prosthesis group (10.0% vs. 23.3%, p = 0.034), and the difference remained significant after adjusting for other factors on multivariate logistic regression analysis (p = 0.024, odds ratio = 3.259). The rate of revision surgery was also significantly lower in the autologous tissue group (1.4% vs. 15.0%, p = 0.004). In our study, the reconstruction method was associated with the development of necrotic complications of the mastectomy flap. Careful selection of patients and reconstruction methods may reduce the risk of mastectomy flap complications in NSM.

Nipple-Sparing Mastectomy in Patients with a History of Reduction Mammaplasty or Mastopexy

Nipple-sparing mastectomy has gained popularity, but the question remains of whether it can be offered safely to women with a history of reduction mammaplasty or mastopexy. The authors present their experience with nipple-sparing mastectomy in this patient population. Patients at the authors' institution who had reduction mammaplasty or mastopexy before nipple-sparing mastectomy were identified. Outcomes measured include nipple-areola complex viability, mastectomy flap necrosis, infection, presence of cancer in the nipple-areola complex, and breast cancer recurrence. The records of the nipple-sparing mastectomy patients at the authors' institution from 2006 through 2012 were reviewed. The authors identified 13 breasts in eight patients that had nipple-sparing mastectomy following reduction mammaplasty or mastopexy. Within this subset of patients, the mean age was 46.6 years and the mean body mass index was 25.1. Nine of 13 breasts had therapeutic resections, whereas the remaining four were for prophylactic indications. Average time elapsed between reduction mammaplasty or mastopexy and nipple-sparing mastectomy was 51.8 months (range, 33 days to 11 years). In all cases, prior reduction mammaplasty/mastopexy incisions were used for nipple-sparing mastectomy. Ten breasts underwent reconstruction immediately with tissue expanders, one with a latissimus dorsi flap with immediate implant and two with immediate abdominally based free flaps. Complications included one hematoma requiring evacuation and one displaced implant requiring revision. There were no positive subareolar biopsy results, and the nipple viability was 100 percent. Mean follow-up time was 10.5 months. The authors' experience demonstrates that nipple-sparing mastectomy can be offered to patients with a history of reduction mammaplasty or mastopexy with reconstructive outcomes comparable to those of nipple-sparing mastectomy alone. Therapeutic, IV.

Comparison of Sterile Versus Nonsterile Acellular Dermal Matrices for Breast Reconstruction

Acellular dermal matrix (ADM) has been associated with an increased incidence of complications after implant-based breast reconstruction. Recently, sterile ADM has been introduced in an attempt to minimize these complications. To analyze the impact of this product on patient outcomes, we created a database of patients undergoing implant-based breast reconstruction. Patients undergoing implant-based breast reconstruction at the University of Kentucky Medical Center from January 1, 2011, to December 31, 2011 were identified. A database of patient characteristics and outcomes was created. Outcomes investigated included mastectomy flap necrosis, dehiscence, infection, red breast, capsular contracture, hematoma, and seroma. Statistical analysis was performed. Fifty-eight patients underwent breast reconstruction with implants or tissue expanders. Of the 58 patients, 9 had the sterile form of ADM placed, 25 had the original aseptic but not sterile ADM, and 24 were not reconstructed with ADM. The most frequent complication noted was seroma, occurring in 6/9 patients with sterile ADM as compared to 2/25 with the aseptic ADM. This was statistically significant (P = 0.003). The use of sterile ADM is associated with a statistically significant increase in seroma formation. The etiology of this increased incidence remains unknown, but it correlates with the introduction of the sterile form of ADM at our institution. A different preparation or sterilization process, or some other variable as yet unknown, may be responsible. Further studies comparing the different forms of ADM in an animal model may serve to clarify this issue.

SPY-Q Analysis Toolkit Values Potentially Predict Mastectomy Flap Necrosis

Previously, we and other investigators have reported the benefits of using SPY Intraoperative Perfusion Assessment System to assist in the prediction of mastectomy flap necrosis. To date, analysis of the SPY images has been subjective. However, the new SPY-Q postprocessing software allows for objective quantification of SPY images through the application of absolute and relative values of fluorescence intensity. This study seeks to determine the use of these objective, numerical data and their role in potentially predicting mastectomy flap necrosis. In a retrospective fashion, 20 SPY images from immediate breast reconstructions were randomly selected from a database of more than 100 images: 10 from breasts that developed flap necrosis and 10 from breasts that demonstrated adequate healing. Groups were matched for age, body mass index, and comorbidities. The points of necrosis and points of adequate healing were evaluated using the postprocessing software, and the groups were compared. The mean "relative" fluorescence of the necrosis and the adequate healing groups was 25.2% and 43.3%, respectively (P < 0.001). The mean absolute fluorescence of the 2 groups was 18.5 and 25.0, respectively (P = 0.07). These findings suggest that quantitative "relative" perfusion values as generated by the postprocessing software may augment clinical judgment of flap viability in an objective and reproducible fashion.

Management of the Ptotic or Hypertrophic Breast in Immediate Autologous Breast Reconstruction

The Wise pattern can be used in mastectomies to address the excess skin in the ptotic or hypertrophic breast; however, limitations include mastectomy flap necrosis (MFN) and poor shape. The vertical pattern can potentially reduce the amount of MFN with improved aesthetic results. This study compares the Wise and vertical mastectomy patterns in immediate, autologous breast reconstruction. Thirty-three patients with grade 2 or 3 ptosis who elected to undergo immediate, autologous breast reconstruction were prospectively recruited into 2 nonrandomized cohorts. Of total, 17 patients (26 reconstructions) had Wise pattern and 16 (28 reconstructions) had vertical pattern. All patients were followed for MFN, time for wound healing, and postoperative complications. Patient and surgeon surveys rated the aesthetics of the reconstructions. The 2 groups did not differ in age, body mass index, smoking, or breast measurements. The Wise group had significantly larger areas of MFN, higher number of postoperative visits, and longer wound-healing periods, compared with the vertical group (P < 0.05). There was no difference in time to adjuvant therapy or additional procedures. Patient surveys rated both incisions with equal satisfaction, except for symmetry that rated better in the Wise group. Surgeon surveys showed better scores for the vertical incision. The Wise pattern is associated with significantly more MFN and prolonged wound care. Despite this complication, patients rate their breast reconstructions favorably, regardless of the type of incision. Both the Wise and vertical patterns can be safely used in skin-sparing mastectomies with immediate, autologous breast reconstruction with good aesthetic outcomes. The authors recommend the vertical pattern because of less MFN and surgeon-preferred aesthetics.

Synergistic Interactions with a High Intraoperative Expander Fill Volume Increase the Risk for Mastectomy Flap Necrosis

PurposeProsthetic-based breast reconstruction is performed with increasing frequency in the United States. Major mastectomy skin flap necrosis is a significant complication with outcomes ranging from poor aesthetic appearance to reconstructive failure. The present study aimed to explore the interactions between intraoperative fill and other risk factors on the incidence of flap necrosis in patients undergoing mastectomy with immediate expander/implant-based reconstruction.MethodsA retrospective review of 966 consecutive patients (1,409 breasts) who underwent skin or nipple sparing mastectomy with immediate tissue expander reconstruction at a single institution was conducted. Age, body mass index, hypertension, smoking status, premastectomy and postmastectomy radiation, acellular dermal matrix use, and application of the tumescent mastectomy technique were analyzed as potential predictors of flap necrosis both independently and as synergistic variables with high intraoperative fill. The following three measures of interaction were calculated: relative excess risk due to interaction, attributable proportion of risk due to interaction, and synergy index (SI).ResultsIntraoperative tissue expander fill volume was high (≥66.7% of the maximum volume) in 40.9% (576 of 1,409 breasts) of cases. The unadjusted flap necrosis rate was greater in the high intraoperative fill cohort than in the low fill cohort (10.4% vs. 7.1%, p=0.027). Multivariate logistic regression did not identify high intraoperative fill volume as an independent risk factor for flap necrosis (odds ratio 1.442, 95% confidence interval 0.973-2.137, p=0.068). However, four risk factors were identified that interacted significantly with intraoperative fill volume, namely tumescence, age, hypertension, and obesity. The SI, or the departure from additive risks, was largest for tumescence (SI, 25.3), followed by hypertension (SI, 2.39), obesity (SI, 2.28), and age older than 50 years (SI, 1.17).ConclusionIn the postmastectomy, hypovascular milieu, multiple risk factors decreasing flap perfusion interact with high intraoperative fill volume to cross a threshold and synergistically increase the risk of flap necrosis.

Evaluating Sterile Human Acellular Dermal Matrix in Immediate Expander-Based Breast Reconstruction

Human acellular dermal matrices have gained increasing use in immediate expander-based breast reconstruction. However, some studies suggest that these grafts may be associated with a higher incidence of infection and seroma. To evaluate complication rates after matrix-based breast reconstruction, the authors conducted a prospective, multicenter, cohort study to evaluate a sterile human acellular dermal matrix in immediate expander-based breast reconstruction, specifically, to determine whether it offered a more favorable risk profile with respect to infection and seroma. A secondary purpose was to determine whether the sterilization process affects graft incorporation. The authors performed 65 consecutive tissue expander-based breast reconstructions in a cohort of patients over a 1-year period using a single protocol. Sterile human matrix was used in all cases. The patients were evaluated for early complications (infection, seroma) and graft incorporation at the time of exchange or definitive reconstruction. Biopsies were performed in the first 20 reconstructions to provide histologic correlation of graft incorporation. Complications occurred in three breasts (4.6 percent), including one case of cellulitis (1.5 percent) and two cases of partial mastectomy flap necrosis (3.0 percent) that required débridement. There were no seromas or explantations. The grafts were incorporated in all cases and verified histologically in the first 20 biopsies. Sterile human acellular dermal matrix can offer reliable matrix incorporation and a low complication rate. Sterilization does not negatively impact incorporation of the graft. The infection and seroma rates in this prospective study compare favorably to those in previous studies with nonsterilized (aseptic) acellular dermal matrix.

The Lateral Inframammary Fold Incision for Nipple-Sparing Mastectomy: Outcomes from Over 50 Immediate Implant-Based Breast Reconstructions

Nipple-sparing mastectomy (NSM) as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. We reviewed 55 consecutive NSMs performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and June 2011. Prior to incision, breasts were lightly infiltrated with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Mean patient age was 46 years, and mean follow-up time was 12 months. Twelve mastectomies (22%) were therapeutic, and the remaining 43 (78%) were prophylactic. Seven of the nine sentinel lymph node biopsies (including one axillary dissection) (78%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 34 (62%) breasts. Average permanent implant volume was 416 cc (range 176-750 cc), and average fat grafting volume was 86 cc (range 10-177 cc). In one patient a positive intraoperative subareolar biopsy necessitated resection of the nipple-areola complex (NAC), and in two other patients NAC resection was performed at a subsequent procedure based on the final pathology report. Mastectomy flap necrosis, requiring operative debridement, occurred in two breasts (4%), both in the same patient. One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Three nipples (6%) required office debridement for partial necrosis and operative reconstruction later. No patient had complete nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin and/or nipple necrosis (p = 0.35). Three episodes (5%) of cellulitis occurred, which responded to antibiotics without the need for explantation. Morphological outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic than the preoperative breasts (196 versus 248 cc, 80 versus 90 mm, 146 versus 134 mm, p < 0.01 for each parameter). Excellent results can be achieved with immediate implant-based reconstruction of NSM through a lateral IMF incision. NAC survival is reliable, and complication rates are low.

Laser Angiography as a Predictor of Mastectomy Flap Necrosis after Breast Reconstruction

Sir:FigureSkin-sparing mastectomy improves the aesthetic result of the reconstructed breast and broadens the reconstructive options. However, areas of ischemia leading to necrosis can prove difficult to clinically assess. We review our experience with laser angiography as a predictor of mastectomy skin flap necrosis. All women who were to undergo immediate postmastectomy breast reconstruction were candidates for this study. Women with an allergy to iodinated contrast dye were excluded. All mastectomy flaps in patients undergoing immediate breast reconstruction over a 2-year period were studied. The vascularity of each flap was initially assessed clinically, and simultaneous intraoperative images were obtained using infrared fluorescent tissue angiography (SPY SP2001; Novadaq, Mississauga, Ontario, Canada) with indocyanine green (Akorn, Inc., Buffalo Grove, Ill.). For performance of the indocyanine green angiography, 4 ml (2.5 mg/ml) of indocyanine green was infused through a peripheral intravenous catheter by the anesthesia personnel, followed by a 10-ml saline flush. Eight seconds after infusion, real-time fluorescent videoangiography of the mastectomy flaps was captured for 1 minute using the Novadaq SPY SP2001 imaging laser. Any portion of the mastectomy flaps that did not appear viable by clinical examination was excised. No tissue was excised based on indocyanine green fluorescence alone. Postoperatively, the amount of fluorescence (fluorescence level) throughout each saved image was calculated (SPY-Q; Novadaq), with relative percentages of fluorescent brightness noted when compared with the most well-perfused area of each respective flap (or brightest, regarded as 100 percent). The fluorescent images and respective postoperative photographs were then compared and areas of ischemic necrosis were correlated. Two hundred twenty-seven mastectomy flaps in 174 patients were studied. Poorly perfused mastectomy flap skin, as determined clinically, was resected. However, mastectomy flap necrosis occurred in 10 breasts (4.41 percent). Four of the 10 (40 percent) developed full-thickness necrosis requiring débridement, and the remaining six breasts (60 percent) developed partial-thickness necrosis and healed with conservative care. However, all areas of necrosis displayed a fluorescence level of 18 percent or less (positive predictive value, 100 percent) (Figs. 1 and 2). All reconstructions were salvaged using the original procedure.Fig. 1: Intraoperative laser image of left mastectomy flaps showing areas with a fluorescence level less than 18 percent (blue circled islands).Fig. 2: Postoperative necrosis correlating to Figure 1.Because of its reliable intravascular pattern and its ability to be used multiple times in a single operation, indocyanine green with near-infrared fluorescence has gained increased utility in plastic surgery. Many large-volume clinical studies have supported its use in breast surgery, ranging from breast reduction, to mastectomy flap assessment, to breast reconstruction.1–5 In addition, although plastic surgery will likely remain largely objective in technique and outcome, objective determination of meaningful tissue ischemia may help decrease reoperation rates and ultimately improve surgical outcomes and patient safety. In our study, we determined that a relative fluorescence level of 18 percent or less predicted partial- or full-thickness mastectomy flap necrosis. We also found that comorbid medical conditions, such as exposure to radiation and smoking, positively correlated to necrosis depth. John D. Murray, M.D. Glyn E. Jones, M.D. Eric T. Elwood, M.D. Lisa A. Whitty, M.D. Chris Garcia, B.S. University of Illinois College of Medicine at Peoria, Peoria, Ill. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this article.

P2-16-09: Nipple-Areolar Sparing Mastectomy: Utility of the Lateral Inframammary Incision in Immediate Implant-Based Reconstructions.

Abstract Purpose: Nipple and/or areola-sparing mastectomy as a therapeutic or prophylactic procedure for breast cancer is rapidly gaining popularity as the literature continues to support it safety. The lateral inframammary fold (IMF) approach provides adequate exposure and eliminates visible scars on the anterior surface of the breast, making this incision cosmetically superior to radial or periareolar approaches. Methods: We reviewed 58 consecutive nipple and/or areola-sparing mastectomies performed through a lateral IMF incision with immediate implant-based reconstruction, with or without tissue expansion, between June 2008 and February 2011. Prior to incision, breasts were lightly tumesced with dilute anesthetic solution with epinephrine. Sharp dissection, rather than electrocautery, was used as much as possible to minimize thermal injury to the mastectomy flap. When indicated, acellular dermal matrix was placed as an inferolateral sling. Subsequent fat grafting to correct contour deformities was performed in select patients. Three-dimensional (3D) photographs assessed changes in volume, antero-posterior projection, and ptosis. Retroareolar/nipple tissue underwent routine intraoperative frozen section analysis in cancer cases. Results: Mean patient age was 44 years, and mean follow-up time was 14 months. Depending upon the judgment of the oncologic surgeon, 44 (76%) mastectomies were nipple/areola-sparing, and 14 (24%) were areola-sparing. Thirteen mastectomies (22%) were therapeutic, the remaining 45 mastectomies (78%) were prophylactic. Five of the nine sentinel lymph node biopsies (56%) were performed through the lateral IMF incision without the need for a counter-incision. Acellular dermal matrix was used in 44 (76%) breasts. Average permanent implant volume was 313 cc (range 170 to 750 cc), and average fat grafting volume was 90 cc (range 36 to 177 cc). Mastectomy flap necrosis, requiring operative debridement, occurred in three breasts (5%). One of these breasts required a salvage latissimus dorsi myocutaneous flap to complete the reconstruction. Of the 44 nipple/areola sparing mastectomies, three (7%) required operative debridement and reconstruction for partial nipple necrosis. No statistically significant differences existed between therapeutic and prophylactic mastectomies for developing partial skin or nipple necrosis (p = 0.65). Morphologic outcomes using 3D scan measurements showed reconstructed breasts were larger, more projected, and less ptotic (196 vs. 248 cc, 80 vs. 90 mm, 146 vs. 134 mm, p &amp;lt; 0.01 for each parameter). Conclusion: Excellent results can be achieved with immediate implant-based reconstruction of nipple and/or areola-sparing mastectomy through a lateral IMF incision. NAC survival is reliable, and complication rates are low. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-09.

P2-16-12: Skin Reducing Nipple Sparing Mastectomy – A Treatment Option for Patients with Significant Ptosis or Macromastia.

Abstract Background: With new data showing the oncologic safety of nipple sparing mastectomy with immediate reconstruction - nipple sparing mastectomies are now offered to an increasing number of mastectomy patients. Unfortunately cosmetically acceptable reconstruction of nipple sparing mastectomies is technically limited to women with perfect breast anatomy - where the skin envelope shows no or little redundancy and where the nipple areolar complex is located in the perfect location on the breast mount. Especially in countries with a high incidence of obesity and associated macromastia only a small percentage of women fall into this category. A high percentahge of patients who would otherwise be good candidates for nipple sparing procedures are excluded based on their unfavorable breast anatomy. We describe a surgical technique that reduces the redundant mastectomy skin envelope in a breast reduction pattern and places the native nipple areolar complex as a free skin graft into proper anatomical position. This technique in conjunction with implant or autologous reconstruction combines the benefits of shorter better vascularized skin flaps with the cosmetic and emotional benefits of preserving the nipple areolar complex even in the anatomically difficult cases. Methods: To investigate the safety and efficiency of this method we reviewed medical records of 40 patients who underwent 60 nipple preserving skin reducing mastectomies over the last 4 years. All procedures were performed by the senior author and follow up ranged from 4 weeks to 50 months. The charts were analyzed for the occurrence of complications such as infection, seroma, hematoma, mastectomy flap necrosis, nipple-areolar loss and loco regional recurrence. All patients were asked to rate their reconstruction on a scale of poor- good - excellent. Results: In 60 reconstructed breasts we encountered one case of seroma, four cases of limited mastectomy flap necrosis treated with local wound care and one case of partial areolar necrosis treated with local excision. No loco regional recurrences, hematomas or infections were encountered. Out of the group of 40 patients, 31 patients rated their result as excellent, 8 as good, and one as poor. Conclusion: Our results compare favorably with data published in the literature. Patient satisfaction rates are high and complication rates are low in a patient population that historically has been a challenge for the breast surgeon, as well as, the plastic surgeon. The use of a skin reducing mastectomy in conjunction with a free nipple graft enables the breast surgeon to offer nipple sparing procedures for all patients who are good oncological candidates regardless of their breast anatomy. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-12.

Laser Angiography as a Predictor of Mastectomy Flap Necrosis after Breast Reconstruction

Plastic and Reconstructive Surgery 128(Supplement 4S):p 86, October 2011. | DOI: 10.1097/01.prs.0000406315.40683.75

Reduction of Mastectomy Flap Necrosis Using Intraoperative Laser-Assisted Indocyanine Green Angiography

Reduction of Mastectomy Flap Necrosis Using Intraoperative Laser-Assisted Indocyanine Green Angiography