Ischemic Complications in Nipple-Sparing Mastectomy: Assessing the Impact of Preserving Optimal Mastectomy Flap Thickness
Jordan D. Frey, MD, Ara A. Salibian, MD, Mihye Choi, MD, Nolan S. Karp, MD.
NYU Langone Medical Center, New York, NY, USA.
The relationship between pre- and post-operative breast flap thickness in nipple-sparing mastectomy (NSM), notably with regards to ischemic complications, has not been evaluated. We therefore aim to evaluate these parameters in NSM using breast magnetic resonance imaging (MRI).
NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre- and post-operative breast MRIs. Demographic, operative variables, and flap thickness were compared for NSMs with and without ischemic complications, defined as nipple or mastectomy flap necrosis.
NSMs with both pre-operative and post-operative breast MRIs (19 total) had an average age of 45.44 years and average body-mass index of 24.16 kg/m2. Seven NSMs were in patients with a smoking history while none were in patients with diabetes mellitus. Thirteen (68.4%) of cases were for a therapeutic indication. Three cases had undergone neoadjuvant chemotherapy while one underwent pre-operative radiation. Five and three underwent adjuvant chemotherapy and radiation, respectively. Eight NSMs underwent tissue expander-based reconstruction, nine underwent immediate, permanent implant reconstruction, and two underwent abdominally-based autologous reconstruction. Average follow-up time was 42.92 months.
In these cases, average total pre-operative NSM flap thickness was 11.9 mm. Average total post-operative NSM flap thickness was 8.0 mm. The overall average post-operative NSM flap thickness was 68.2% of the overall average pre-operative NSM flap thickness. Average
overall post-operative NSM flap thickness was significantly less than average overall pre-operative NSM flap thickness (p<0.0001).
Five NSMs (26.3%) had ischemic complications; there were two incidences each of major mastectomy flap necrosis, minor mastectomy flap necrosis, and partial NAC necrosis (10.5%) and one incidence of complete NAC necrosis (5.3%). Significant difference was noted in terms of overall (13.4 vs. 11.3 mm; p=0.0422) NSM flap thickness on pre-operative MRI in those with ischemic complications. Based on post-operative MRIs in this group, NSMs with ischemic complications trended towards less overall flap thickness (7.0 vs. 8.4 mm; p=0.1144). NSMs with ischemic complications were found to have a significantly lower post-overall post-operative to pre-operative flap thickness based on pre- and post-operative MRI measurements percentage (52.0% vs. 74.0%; p<0.0001).
Average overall NSM flap thickness was significantly less compared to the pre-operatively identified flap thickness. The ratio of post-operative to pre-operative NSM flap thickness was significantly lower in reconstructions with ischemic complications.
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