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BACKGROUND:Single-staged breast reconstruction has long been the goal of the breast reconstruction community and nearly every major advance in our field has headed in this direction. Recent evolutions of oncologic breast surgery and reconstruction_the nipple-sparing mastectomy and perforator-based (muscle and fascia-sparing) autologous breast reconstruction_now allow surgeons to offer the appropriate patients a single-staged, autologous tissue reconstruction with the least donor site morbidity. We present our series of buried perforator-based free flaps in nipple-sparing mastectomies as proof of concept, as well as to explore indications, techniques, and early outcomes from our series.
METHODS:From 2001 to 2011, a total of 2,132 perforator-based free flaps for breast reconstruction were reviewed from our prospectively maintained database.
RESULTS:There were 208 free flaps performed on 130 patients following nipple-sparing mastectomy. Among these were 21 patients who underwent breast reconstruction with buried free flaps, totaling 40 buried free flaps after nipple-sparing mastectomy (19.2%). BRCA mutations were the most common diagnoses represented in 14 patients (66.7%). Other diagnoses included ductal carcinoma in situ (5 patients), invasive ductal carcinoma (2 patients), lobular carcinoma (1 patient), and atypical lobular hyperplasia (1 patient). Most patients were reconstructed with perforator flaps from the abdomen, although other donor sites were selected as well. There were 27 deep inferior epigastric perforator flaps, 5 transverse upper gracilis flaps, 2 profunda artery perforator flaps, 2 superior gluteal artery and 2 inferior gluteal artery perforator flaps, 1 superficial inferior epigastric artery flap, and 1 deep femoral artery perforator flap. The average flap weighed 439 grams and the majority of procedures (75.0%) were performed using a vertical incision, 8 via a lateral incision, and 2 with an inframammary incision. An implantable Cook-Swartz Doppler was utilized for flap monitoring in 32 flaps (80.0%). A single complication of venous outflow obstruction required revision (2.5%). There were no flap losses. Five patients (23.8%) underwent minor secondary procedures, while sixteen patients (76.1%) remained satisfied with their single-stage autologous breast reconstruction.
CONCLUSIONS: We conclude that nipple-sparing mastectomy with immediate autologous breast reconstruction can be performed safely in a single stage; however, we are not ready to offer this as our standard of care and will continue to collect more data to thoroughly evaluate the risks and benefits of this operation.