Wise Pattern Incision Research Articles

Comparing Wise Pattern to Non-Wise Pattern Skin Sparing Mastectomy: A Critical Evaluation of Patient Demographics and Surgical Outcomes.

Multiple skin-sparing incisions are utilized in immediate post-mastectomy breast reconstruction; however, the Wise pattern incision (WPI) may have superior cosmetic outcomes for large ptotic breasts compared to non-Wise pattern incisions (NWPI). We evaluated patient demographics and surgical outcomes with WPI versus NWPI. An electronic medical record search was performed for patients at a single academic institution from 2019 to 2022 with ICD-10-CM diagnosis code "Z42.1: encounter for breast reconstruction following mastectomy." Retrospective chart review evaluated patient demographics, intraoperative factors, postoperative complications, and surgical cost. 288 patients were included; 58 had WPI and 230 had NWPI. Median BMI differed between WPI (30.5) and NWPI (26.4) (P < 0.001). 57% of WPI had preoperative grade 3 ptosis versus 23% of NWPI (P < 0.001). No difference was found in median operative times (WPI: 219 minutes, NWPI: 194 minutes, P = 0.38). Overall rates of postoperative complications differed between WPI (62%) and NWPI (45%) on univariate, but not multivariate, analysis. Median total surgery charge was higher for WPI (WPI: $36,223, NWPI: $31,185, P < 0.001), while implant cost was higher for NWPI (WPI: $2,700, NPWI: $8,040, P < 0.001). There was no significant difference in operative time, overall complication rate, or charge between incision types once adjusted for confounding factors. The higher complication rate in the WPI group was likely driven by higher BMI, a known risk factor for surgical complications regardless of approach. Surgeons can consider WPI as a noninferior option for patients with higher BMI and ptosis.

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.

How do women perceive their breast image before and after bilateral therapeutic mammoplasty for early breast cancer?

IntroductionBilateral therapeutic mammoplasty (BTM) is commonly performed in the UK during treatment for breast cancer, and the available data show oncological safety. This study aims to compare patient-recorded outcome measures before and after surgery, as well as associated patient factors. MethodsBetween March 2018 and December 2019, patients undergoing BTM for breast cancer completed validated BREAST-Q reduction modules before and 3 months after surgery and a radiotherapy domain at 3 months. Scores were correlated with clinical data. For BREAST-Q scales, a higher score (0–100) represents greater satisfaction or quality of life. Results28 patients were included, median age 58 years (IQR 52–64), BMI 32.0 (IQR 27.8–34.0). Of these, 1 had bilateral disease, 2 had multifocal disease, and the remaining had unilateral disease. Most (55%) underwent Wise pattern incision. At 3 months post-operatively, the following outcome scores improved based on the Wilcoxon signed-rank test: satisfaction with breasts (median 44 to 84; p < 0.001), psychosocial wellbeing (57.5 to 83; p < 0.001) and sexual wellbeing (48 to 61; p = 0.029). The improvement in satisfaction with breasts score correlated with the preoperative score (p = 0.011), with a larger increase in patients with a lower baseline score.Physical wellbeing was unchanged overall (median 71 to 72). In all solely post-operative domains (satisfaction with information, outcome, nipples and following radiation), patients reported high levels of satisfaction with outcomes. ConclusionsPatients reported improved levels of patient-related quality of life measures after therapeutic mammoplasty, including satisfaction with breasts and psychosocial and sexual wellbeing, with high post-operative outcomes in satisfaction with outcome, information and nipples, as well as radiation Q-score.

Immediate prepectoral breast reconstruction in nipple-sparing mastectomy with Wise-pattern incision in large and ptotic breasts: Our experience and short-term results

IntroductionCurrent trends in treatment of breast cancer advocate nipple-sparing mastectomy (NSM) as the technique of choice in selected patients. A large and ptotic breast is often considered a relative contraindication for NSM, due to the increased risk of skin and nipple necrosis. MethodsA retrospective review was performed for patients who underwent immediate prepectoral breast reconstruction (PPBR) after NSM with Wise-pattern incision between February 2020 and February 2023 at our institution. This procedure was offered to patients with grade II or III ptosis or large breasts who were candidates to NSM for therapeutic or prophylactic purpose. Exclusion criteria were: a preoperative nipple-sternal notch distance greater than 30cm, previous radiotherapy, pinch test < 1cm, BMI greater than 34 and active smoke. We present our short-term results with this technique. ResultsDuring the considered period, 62 patients (76 breasts) had NSM with Wise-pattern incision. Patients had immediate PPBR with implant or tissue expander, both entirely wrapped with ADM. The median age of the patients was 57.0 years (IQR 50.0-68.6) with a median BMI of 25.5 (IQR 23.3-28.4). The median mastectomy specimen weight was 472g (341-578). Median implant volume was 465g (IQR 370-515). Major complications occurred in 8 patients (10.5%). Three patients had total NAC necrosis (3.9%), partial NAC necrosis occurred in 2 patients (2.6%). Two patients developed implant infection (2.6%). Univariate analysis showed a statistically significant correlation between major complications and the mastectomy specimen weight (p 0.003). ConclusionsIf oncologically indicated, NSM with Wise-pattern incision and immediate PPBR can safely be performed in selected patients with large and ptotic breasts.

The Underused Superomedial Pedicle Reduction Mammaplasty: Safe and Effective Outcomes.

The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series. A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included. A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch-to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch-to-nipple distance. Body mass index ( P = 0.029) and breast reduction specimen operative weight ( P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months. The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes. Therapeutic, IV.

Fleur-de-lis-like incision for Wise pattern superior-pedicle oncoplastic breast cancer surgery

Background: Wise pattern is one of the most common oncoplastic approaches to breast conserving surgery, particularly in large and ptotic breast. However, it results in long dermal flaps with a possible risk of skin necrosis or even wound dehiscence, most likely at the T-junction area. The aim of this study was to evaluate a modification of the Wise pattern incision in terms of T-junction protection.

Extended dermal sling for implant-based immediate prepectoral breast reconstruction in large ptotic breasts without using a mesh in early breast cancer

Background The rate of immediate breast reconstruction after mastectomy for early breast cancer has recently increased owing to the technological advancements in tissue expanders and implant designs, acellular dermal matrices, and fat grafting. The use of an extended dermal sling to cover the implant in patients with large ptotic breast allows prepectoral breast reconstruction, avoiding the complications and pitfalls of pectoralis muscle elevation and evading the use of the acellular dermal matrices with its high cost and being a foreign material. Patients and methods A total of 22 patients underwent mastectomy through a Wise pattern incision. The de-epithelialized extended dermal sling was used to create a prepectoral pocket for the implant and sutured to the pectoralis fascia. Results The median BMI was 31.5 kg/m2 (range, 28–39). The median distance between the areola and the inframammary fold was 20.3 cm (range, 18–26). A total of 13 patients had permanent implant and nipple graft, whereas nine patients had a tissue expander. The average implant size was 375 ml (range, 325–450). Three patients developed seroma around the implant. One patient had mild erythema and two patients had delayed wound healing. Two patients developed partial nipple necrosis. One patient experienced infection and wound dehiscence mainly at the T-junction, and the vertical limb, which was managed by a re-do surgery, removal of the implant, and insertion of a tissue expander. The average follow-up was 14 months (range, 8–24). Conclusion Extended dermal sling is a safe, reliable, and effective option for immediate prepectoral breast reconstruction after mastectomy for patients with early breast cancer who have a large ptotic breast. It has a great advantage of being an autologous tissue with minimal complications and good esthetic results.

Autologous Breast Reconstruction with Free Nipple-Areola Graft after Circumareolar (Skin Reducing) Mastectomy.

Introduction of skin-sparing mastectomy (SSM) led to a paradigm shift in breast reconstruction. Primary reconstructions have become the therapy of choice. At the same time, immediate autologous reconstructions are oncologically safe and aesthetically pleasing. Our preferred SSM incision is the circumareolar with removal of nipple and areola (NAC). Adjustment of the skin envelope is well accomplished in mild-to-moderate ptotic breasts. We describe our technique consisting of circumareolar incision in SSM, keeping the NAC as a free graft, and immediate autologous reconstruction and immediate free NAC grafting on the flap. Aesthetic indications are slight asymmetries, ptotic breasts, large breasts where the reconstructed breast will be smaller than the original breast and where a Wise pattern is not indicated. Oncologic indications are risk-reducing mastectomies and tumors close to the NAC where resection would compromise the vitality of the NAC. We evaluated the healing of the NAC and the NAC position with regard to the breast shape. From 2019–2022, 296 autologous flaps were used for breast reconstruction. In 36 flaps, this technique was applied. Eighteen flaps were bilateral (nine patients). In total, we performed 15 inner thigh flaps and 21 DIEP flaps. No flap or NAC loss occurred. There was no wound healing complication at the breast, and no adjuvant chemotherapy or radiation therapy needed to be postponed. The advantages of this technique are (1) scar reduction with only one periareolar scar on the breast, which is also well concealed; (2) oncological safety in relation to the nipple and optimal visibility of the mastectomy cavity, which allows a meticulous mastectomy, especially important in risk-reducing mastectomies; (3) generally, fewer wound healing problems, especially fewer than with Wise pattern incision; (4) primary adjustment of the skin envelope and positioning of the NAC are easier to perform than in a secondary procedure; and (5) that the NAC is spared, and no secondary reconstruction is necessary. Disadvantages are that (1) the NAC must heal as a free graft and (2) that the sensitivity of the NAC is lower than in pedicled NAC transposition.

Mastopexy using de-epithelialised dermoglandular flaps: a case series for maximal volume conservation following breast implants removal

Aims and objectiveRemoval of implants without replacement is often requested, and the procedure is more commonly performed today than ever before. However, the resultant loss of body image, secondary to the loss of breast volume, is not an outcome, that a patient is looking forward to. There is a lack of information on the options available to the patients following explantation. This case series presents an option of breast volume preservation and reshaping during mastopexy after breast implant removal that can be offered to selected patients. In the current case series, de-epithelialised dermoglandular flap mastopexy was used as an autologous tissue for breast reshaping and remodelling.Material and methodsSince 2015, ten patients were selected for de-epithelialised dermoglandular mastopexy using wise pattern or vertical scar. Surgery was performed under general anaesthesia as a day case. A vertically oriented bipedicular dermoglandular flap was used for vertical scar mastopexy in two patients, and eight patients had Wise pattern incisions. Of these eight patients, four had superomedial and four had inferiorly based flaps for dermoglandular mastopexy and closure. All patients had a preoperative cup size D or larger.ResultsAll patients had adequate results with an acceptable breast cup size. There was no skin breakdown, nipple loss, haematoma or infection.ConclusionDe-epithelialised dermoglandular flap mastopexy is a safe procedure and can be used as an option in selected patients.Level of EvidenceIV.

The Goldilocks Procedure with and without Implant-Based Immediate Breast Reconstruction in Obese Patients: The Mayo Clinic Experience.

Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only. A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed. One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups. The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction. Therapeutic, III.

Augmentation Mastopexy with Surgical Excision of the Lower Pole to Avoid Waterfall Deformity: A Surgical Technique and Nipple Areolar Complex Case Series.

Purpose of this article is to demonstrate a way of avoiding the waterfall deformity in augmentation mastopexy patients. We will show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking breast augmentation who also require mastopexy. We will show how addressing the breast parenchyma on the lower pole via direct excision can give reliable results and avoids the waterfall deformity. The surgical technique used by the senior author combines the principles of breast augmentation, mastopexy, and breast reduction. We apply these principles during the initial single operation. Our goal is to achieve the best anatomical results for the patient. We describe 1538 consecutive patients whom underwent single-stage breast augmentation with mastopexy. All implants were submuscular with 12% being saline and 88% were silicone implants. Vertical mastopexies were performed in 8% and wise pattern incisions were used in 92%. There were no life-threatening complications such as deep vein thrombosis, pulmonary embolism, and so on. Tissue-related complications included wound infection (1%) and hematomas (1%). Implant-related complications included malposition or implant displacement 9% and capsular contracture 1%. Aesthetic complications included dystopia of NAC (4%) and volume asymmetries (10%). Revision surgery was tissue related (2%), implant related (3%), and aesthetic related (10%). There were no cases of waterfall deformity seen in the cohort. In conclusion, we believe that the technique detailed here is easy to do, uses principles already known of breast augmentation and reduction and gives consistent results with low reoperation rates.

Single-port three-dimensional endoscopic subcutaneous mastectomy for gynaecomastia: an aesthetically superior and novel approach

Gynaecomastia is a benign clinical condition that can occur in men of all ages, attributed by the proliferation of glandular tissue. Most patients are asymptomatic while symptoms ranging from mild discomfort to severe pain can present in patients with gynaecomastia. In addition to these, this condition may affect the psychological well-being of patients leading to a need for further treatment. Medical treatment of primary gynaecomastia in the form of anti-oestrogen therapy has not been proven to be effective and there is no consensus regarding the drug of choice or optimal duration of treatment. Surgical treatment is usually the standard treatment in primary gynaecomastia. There have been various techniques described in the literature with the aim of restoring a pleasant chest shape with limited scar on incision. Most of the techniques however involve the use of a peri-areolar or a Wise pattern incision, which can be obvious, especially in patients with a tendency to scar badly. The authors describe a novel approach, whereby a single-port endoscopic subcutaneous mastectomy using the three-dimensional endoscopic system with incision placed along the anterior axillary line was performed for a patient with gynaecomastia and thereby conferring excellent aesthetic outcomes.

Abstract: Incision Choices in Nipple-Sparing Mastectomy: A Comparative Analysis of Outcomes and Evolution of a Clinical Algorithm

PURPOSE: Nipple-sparing mastectomy (NSM) allows for preservation of the entire nipple-areola complex utilizing various unique incision patterns. Reconstructive trends and overall risk associated with these diverse NSM incisions have yet to be fully established. 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. Mastectomy incisions other than these were excluded from analysis. Descriptive statistics and measures of central tendency were used to describe absolute and mean results. ANOVA and Chi-squared analysis were used to compare groups in terms of demographics and outcomes. Full and reduced model multivariate analyses were performed to identify the independent effect of mastectomy incision type on the occurrence of any complication. p-Values <0.05 were deemed significant. 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. Demographics for each NSM incision were heterogeneous and differed significantly with regards to age (p<0.001), body-mass index (p<0.001), smoking (p=0.001), diabetes mellitus (p<0.001), mastectomy indication (p<0.001), prior chemotherapy (p=0.006), mastectomy laterality (p<0.001), performance of a sentinel lymph node biopsy (p<0.001), pathologic cancer stage (p<0.001), reconstruction modality (p<0.001), adjuvant chemoradiation (p=0.031; p=0.002), and follow-up time (p<0.001). The groups were similar with regards to prior radiation (p=0.386) and sentinel lymph node biopsy positivity (p=0.327). A crude, unadjusted multivariate logistic regression analysis examining for the occurrence of any complication revealed a significant difference among the six cohorts of varying NSM incisions (p<0.001). Two bookend cohorts emerged with vertical radial (16.1%) and inframammary fold incisions (21.0%) having lower overall complication rates while lateral radial (31.6%), Wise pattern (50.0%), previous (45.7%), and periareolar (36.8%) experienced higher overall rates. Post-hoc adjusted z-tests were performed which identified the vertical radial and inframammary fold incision cohorts as homogeneous subgroups. Full and reduced models of the multivariate logistic regression analysis were then performed to determine adjusted outcomes. The Hosmer and Lemeshow chi-square test results were insignificant for both the full and reduced multivariate regression models (p=0.401; p=0.061), indicating good fit. In the full model, age (p=0.013) and body-mass index (p<0.001) emerged as significant risk factors for the occurrence of any complication with NSM and were included in the reduced model. In the reduced multivariate logistic regression model, inframammary fold incisions (p=0.001) emerged as a significant protective factor for overall complications after adjustment for other factors. Wise pattern incisions (p=0.051) increased the odds of complications, although not quite significantly (p=0.051). Age (p=0.007) and body-mass index (p<0.001) continued to significantly increase risk of complications in this model. CONCLUSION: 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.

The inframammary skin-sparing mastectomy technique

Skin-sparing mastectomy and immediate implant-based breast reconstruction is technically a challenging procedures for women with large, ptotic breasts. This is usually performed using the Wise pattern incision resulting in an inverted T scar, which is associated with postoperative complications. The other challenge is obtaining adequate coverage of the prosthesis. We describe a technique that avoids the inverted T scar and provides a single horizontal scar with a double dermo-muscular layer coverage of the prosthesis.

Nipple-Areola Complex Malposition in Nipple-Sparing Mastectomy: A Review of Risk Factors and Corrective Techniques from Greater than 1000 Reconstructions.

Nipple-areola complex malposition after nipple-sparing mastectomy can be a challenging issue to correct. The current literature is largely limited to smaller series and implant-based reconstructions. A retrospective review of all nipple-sparing mastectomies from 2006 to 2016 at a single institution was performed. Incidence, risk factors, and corrective techniques of nipple-areola complex malposition were analyzed. One thousand thirty-seven cases of nipple-sparing mastectomy were identified, of which 77 (7.4 percent) underwent nipple-areola complex repositioning. All were performed in a delayed fashion. The most common techniques included crescentic periareolar excision [n = 25 (32.5 percent)] and directional skin excision [n = 10 (13.0 percent)]. Cases requiring nipple-areola complex repositioning were significantly more likely to have preoperative radiation therapy (p = 0.0008), a vertical or Wise pattern incision (p = 0.0157), autologous reconstruction (p = 0.0219), and minor mastectomy flap necrosis (p = 0.0462). Previous radiation therapy (OR, 3.6827; p = 0.0028), vertical radial mastectomy incisions (OR, 1.8218; p = 0.0202), and autologous reconstruction (OR, 1.77; p = 0.0053) were positive independent predictors of nipple-areola complex repositioning, whereas implant-based reconstruction (OR, 0.5552; p < 0.0001) was a negative independent predictor of repositioning. Body mass index (p = 0.7104) and adjuvant radiation therapy (p = 0.9536), among other variables, were not predictors of nipple-areola complex repositioning. Nipple-areola complex malposition after nipple-sparing mastectomy can be successfully corrected with various techniques. Previous radiation therapy, vertical mastectomy incisions, and autologous reconstruction are independently predictive of nipple-areola complex malposition. Therapeutic, III.

Oncoplastic Split Reduction with Intraoperative Radiation Therapy

A standard Wise-pattern reduction can be used to excise a breast cancer that falls within the Wise pattern.1 When the tumor is located outside the Wise pattern, it can be removed by tunneling and pulling the lesion through the Wise-pattern incision. When it is necessary to take skin overlying the tumor, the Wise pattern can be reconfigured by moving either the lower inner or lower outer quadrant triangles, which are a normal part of the standard Wise pattern, to a position over the tumor. This change must be accompanied by splitting the vertical limb of the reduction to accommodate the repositioning of the triangle, a technique known as split reduction.2 This alteration in the Wise pattern removes the skin directly over the tumor and guarantees that the anterior margin will be clear. Intraoperative radiation therapy (IORT) is a technique used for administering a single dose of radiation therapy given during a ‘lumpectomy’ procedure. Two prospective, randomized trials have shown that, in selected low-risk patients, IORT may be adequate as the entire course of radiation therapy.3,4 In this video, we combined IORT with a split reduction tumor excision.

P065. Comparison of radial margins in therapeutic mammoplasty and wide local excisions for invasive breast cancer

P065. Comparison of radial margins in therapeutic mammoplasty and wide local excisions for invasive breast cancer

Clinical outcomes following nipple–areola-sparing mastectomy with immediate implant-based breast reconstruction: a 12-year experience with an analysis of patient and breast-related factors for complications

Nipple-sparing mastectomy (NSM) is increasingly offered to women for therapeutic and prophylactic indications. Although, clinical series have been described, there are few studies describing risk factors for complications. The objective of this study is to evaluate the incidence of complications in a series of consecutive patients submitted to NSM and differences between clinical risk factors, breast volume, and different incision types. In a cohort-designed study, 158 reconstructed patients (invasive/in situ cancer and high risk for cancer) were stratified into groups based on different types of incision used (hemi-periareolar, double-circle periareolar, and Wise-pattern). They were matched for age, body mass index, associated clinical diseases, smoking, and weight of specimen. Also included were patients treated with adjuvant chemotherapy and postoperative radiotherapy. Mean follow-up was 65.6months. In 106 (67%) patients, NSM was performed for breast cancer treatment and in 52 (32.9%) for cancer prophylaxis. Thirty-nine (24.6%) patients were submitted to hemi-periareolar technique, 67 (42.4%) to double-circle periareolar incision, and 52 (33%) to Wise-pattern incision. The reconstruction was performed with tissue expander and implant-expander. Local recurrence rate was 3.7% and the incidence of distant metastases was 1.8%. Obese patients and higher weight of specimen had a higher risk for complications. After adjusting risk factors (BMI, weight of specimen), the complications were higher for patients submitted to hemi-periareolar and Wise-pattern incisions. This follow-up survey demonstrates that NSM facilitates optimal breast reconstruction by preserving the majority of the breast skin. Selected patients can have safe outcomes and therefore this may be a feasible option for breast cancer management. Success depends on coordinated planning with the oncologic surgeon and careful preoperative and intraoperative management. Surgical risk factors include incision type, obesity, and weight of breast specimen.

Immediate Definitive Prosthetic Reconstruction in Patients With Ptotic Breasts

Immediate reconstruction of medium/large ptotic breasts can be performed by using expanders, definitive implants, or autologous flaps. If a skin-sparing mastectomy is feasible, excellent results can be achieved by planning Wise pattern incisions, using definitive implants. The authors suggest the use of a dermal-adipose flap, harvested from the ptotic part of the breast, rotated laterally, and interposed between the serratus fascia and the pectoralis muscle to close the inferolateral part of the pocket. We performed 23 immediate unilateral single-stage breast reconstructions, with simultaneous contralateral reduction. Preoperatively, all breasts showed grade II or III ptosis. There was no case of implant infection or failure of the reconstruction. The median follow-up was 21 months; however, some patients followed up for >4 years; in this period, no case of capsular contracture was observed. This technique has provided good shape, acceptable ptosis consistent with the healthy breast and symmetric scars.

A pure dermal sling for implant reconstruction after mastectomy in the generous breast

TECHNIQUE A skin reducing mastectomy is performed via Wise pattern incisions, retaining an extensive inferior dermal sling of de-epithelialised tissue. A sizer is used to ensure the skin envelope meets the inframammary fold before an anatomical implant is placed on the pectoralis major. Complete coverage is achieved with the inferior dermal sling, which is sutured to the pectoralis superiorly. The superior skin can then be draped to the inframammary fold and sutured in the usual manner.