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Nipple-sparing Mastectomy and Immediate Free Flap Reconstruction in the Large Ptotic Breast
Lisa F. Schneider, MD1, Constance M. Chen, MD MPH2, Alan J. Stolier, MD3, Richard L. Shapiro, MD4, Christina Y. Ahn, MD1, Robert J. Allen, MD1.
1Institute of Reconstructive Plastic Surgery, New York, NY, USA, 2New York Eye & Ear Infirmary and Lenox Hill Hospital, New York, NY, USA, 3Omega Hospital, Metairie, LA, USA, 4NYU Cancer Institute, NYU Langone Medical Center, New York, NY, USA.

Background: Nipple-sparing mastectomy (NSM) is growing in acceptance as a technique used for selected patients to optimize reconstructive and aesthetic outcome. Indications for NSM are guided by both oncologic and reconstructive criteria. Due to the increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to NSM. Furthermore, reconstruction of ptotic breasts after NSM has only been reported with tissue expander and implant-based reconstruction. We describe free flap breast reconstruction of the large ptotic breast after NSM.
Methods: A retrospective review was performed of 85 consecutive patients who underwent NSM with 141 perforator free flap breast reconstructions by a single senior reconstructive surgeon from December 2008 to March 2011. All patients underwent immediate reconstruction of large ptotic breasts after NSM using free flaps. Large ptotic breast was defined cup size C or greater. Risk factors examined include BMI and previous breast radiation. Operative technique, timing of secondary procedures and complications, including nipple necrosis, hematoma and total flap loss, were examined.
Results: 19 of 85 patients who underwent NSM had cup size C or greater (n=19). Mean patient age was 47.4 years (range 35-6). Mean BMI was 26.8 (range 21.6-32), and 3 out of 19 patients (15%) had BMI > 30. Out of 19 patients who fit inclusion criteria, breast cup size varied from 34C to 38 DDD. Sternal notch to nipple distance averaged 26.8 cm (range 24-28.5). 10 of 19 patients (50%) underwent prophylactic mastectomies for a strong family history of breast cancer or positive genetic testing for BRCA 1 and 2. No patients had significant medical co-morbidities, including diabetes or smoking history. Only one patient had previous breast radiation prior to NSM. 15 out of 19 patients had bilateral NSM (79%), and 4 out of 19 patients had unilateral NSM (21%) after having had a previous contralateral mastectomy for breast cancer. 6 patients (32%) had NSM through lateral incisions from the nipple toward the axilla, and 13 patients (68%) through vertical incisions from the nipple toward the inframammary fold. One patient underwent a bilateral TUG flap reconstruction (5%); the remaining 18 patients had bilateral DIEP flap reconstruction (95%). With regard to complications, there was 1 case of nipple necrosis (5%), 1 hematoma (5%), and no flap losses. 4 patients (21%) underwent subsequent mastopexy or breast reduction in order to tailor the skin envelope to the underlying free flap. Secondary procedures were performed a mean of 7.3 months after the primary procedure (range 4-10).
Conclusions: Although many surgeons believe large ptotic breasts to be a relative contraindication to NSM, we demonstrate that NSM and free flap breast reconstruction can be safely performed in these patients. Nipple loss is rare, and secondary procedures are only required in a minority of patients. In sum, even in women with large, ptotic breasts, nipple-sparing mastectomy with free flap breast reconstruction is a reliable technique that can be used in selected patients to optimize reconstructive and aesthetic outcome.


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