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Staged composite mastopexy following nipple-sparing mastectomy and autologous breast reconstruction: improving aesthetic outcomes.
Marc A. Soares, MD1, Wojciech Dec, MD2, Neil Tanna, MD, MBA2, Jennifer C. Lehman, MD2, Lauren S. Cassell, MD2, Stephanie F. Bernik, MD2, Oren Z. Lerman, MD2.
1NYU Medical Center, New York, NY, USA, 2North Shore - Long Island Jewish / Lenox Hill Hospital, New York, NY, USA.

BACKGROUND:Nipple sparing mastectomy (NSM) is an increasingly popular technique associated with enhanced patient satisfaction and significant aesthetic benefit. Patients with significant nipple areolar ptosis or insufficient donor site tissue volume relative to breast size are often precluded from nipple-sparing mastectomy due to an aesthetically unacceptable persistence or exacerbation of nipple ptosis following reconstruction. Moreover, mobilization of the nipple areolar complex (NAC) at the time of mastectomy to correct nipple position can lead to necrosis. In such patients, we believe a superior aesthetic result can be achieved utilizing NSM with immediate autologous reconstruction if a second-staged mastopexy is performed to transpose the NAC to the center of the new breast mound on a composite pedicle derived from the flap reconstruction.
METHODS:All NSM reconstructions utilizing abdominally-based autologous breast reconstruction performed by the senior author were analyzed to identify patients who underwent autologous breast reconstruction with significant preoperative ptosis or a significant mismatch between breast size and available donor tissue volume. Patients were analyzed for demographic and clinical information including: indication for NSM, type of autologous reconstruction, grade of preoperative ptosis, sternal-notch to nipple distance, bra-size, BMI, delay between initial reconstruction and second stage mastopexy, adjunctive procedures during secondary mastopexy, history of radiation, surgical complications and aesthetic result/correction of ptosis
RESULTS:7 patients who met the criteria were included in the study. 13 breasts underwent immediate autologous reconstruction (12 DIEP, 1 MS-TRAM) following NSM and were included in the analysis. Invasive cancer was the indication for 4 breasts (31%), while prophylactic mastectomies were performed for the remainder, including 4 breasts with BRCA mutations. The median age of patients included was 50 years with an average BMI of 24.6. Bra cup size ranged from 34B to 36F. 3 patients had grade I ptosis (46%), 4 patients had grade II ptosis (53%), and no patients had grade III ptosis. The average distance between sternal-notch and nipple was 24cm. 2 patients suffered total or partial nipple loss after NSM, prior to second stage mastopexy. The average time between mastectomy and second-stage mastopexy was 197 days. All 7 patients underwent secondary mastopexy including 11 nipple-areolar complexes. The only complication post-mastopexy was a seroma; there was no incidence of NAC necrosis or loss. Autologous fat grafting was performed in 2 patients at the time of mastopexy to augment flap volume.
CONCLUSIONS:Lack of sufficient donor flap volume to adequately fill the mastectomy skin envelope and maintain or correct acceptable NAC position is perceived as a limitation to nipple sparing mastectomy in autologous reconstruction. Using our staged technique of immediate autologous reconstruction followed by mastopexy, utilizing the newly transferred flap-based composite pedicle, we demonstrate expanded indications for NSM in women with larger breasts and/or ptosis with superior aesthetic results. Our technique not only allows for immediate autologous reconstruction, but obviates the need for strategies that employ mastopexy or breast reduction prior to mastectomy that have the potential to risk NAC survival or delay oncologic treatment.

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