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Does Staged Breast Reduction Prior to Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study Between Staged and Non-Staged Techniques
Ara A. Salibian, MD, Jordan D. Frey, MD, Mihye Choi, MD, Nolan S. Karp, MD.
New York University Langone Health, New York, NY, USA.

Background: Nipple-sparing mastectomy (NSM) in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction prior to prophylactic NSM has been shown to decrease complications; however, a direct comparison of outcomes between staged and non-staged techniques is lacking.
Methods: A retrospective review of all patients that underwent staged breast reduction prior to NSM was conducted. Staged cases were matched to non-staged NSM cases according to known risk factors for complications including mastectomy indication, incision pattern, reconstruction type, radiation history and active tobacco use. Individual staged cases with appropriate matches in all these categories were then each paired to two non-staged cases according to the nearest higher and lower mastectomy weight value as a surrogate for breast size (includes breast reduction specimen weight in staged group). Staged and non-staged cohorts were compared with regards to demographics, operative characteristics and reconstructive outcomes.
Results: 18 staged breast reductions were identified, performed at an average of 5.0 months prior to NSM. Wise-pattern skin excision was utilized in 16 cases (88.9%) and vertical in 2 cases (11.1%) with medial (44.4%) or superomedial (55.6%) pedicles and an average reduction weight of 383.3 grams (range: 82-1240).
Staged reductions were matched to thirty-six prophylactic non-staged reductions (Table 1). Average mastectomy weight in the staged group was significantly higher in the staged group (942.1 grams) than in the non-staged group (640 grams) (p=0.0003). The rate of major mastectomy flap necrosis was significantly lower in the staged cohort (0%
versus 22.2%, respectively; p=0.0415) despite a significantly higher average mastectomy weight in the staged group. The staged cohort also had lower rates of minor mastectomy flap necrosis (11.1% versus 16.7%), partial nipple necrosis (11.1% versus 13.9%) and explantation (0% versus 8.3%), though these complications were comparable between the groups. Two breasts in both the staged (11.1%) and non-staged (5.6%) cohorts required correction of nipple malposition (p=0.5963).
Conclusion: In patients with large breast size, staged breast reduction prior to NSM had significantly lower rates of major flap necrosis compared to non-staged cases after controlling for other known risk factors for complications.

Table 1. Comparison of patient demographics, intra-operative characteristics and reconstructive outcomes between staged breast reduction prior to NSM and matched cases
CharacteristicNSM with Staged BR(n=18)Non-Staged NSM (Matched Cohort)(n=36)p-value
Age (years)43.545.60.4723
BMI (kg/m2)25.525.70.8049
Diabetes Mellitus00-
Active Tobacco Use*00-
Previous Radiation*00-
Previous Chemotherapy03 (8.3%)0.5428
Mastectomy Indication*-
Prophylactic18 (100%)36 (100%)
Reconstructive Technique*-
Tissue-expander6 (33.3%)12 (33.3%)
Immediate Implant10 (55.6%)20 (55.6%)
DIEP2 (11.1%)4 (11.1%)
Mastectomy Incision*0.1241
IMF14 (77.8%)32 (88.9%)
Vertical2 (11.1%)4 (11.1%)
Wise-pattern**2 (11.1%)0
Mastectomy weight (grams)*†
Range544 - 1690280- 1324-
Post-operative Radiation00-
Post-operative Chemotherapy01 (2.6%)>0.9999
Reconstructive Complications
Minor mastectomy flap necrosis2 (11.1%)6 (16.7%)0.7043
Major mastectomy flap necrosis08 (22.2%)0.0415
Partial NAC necrosis2 (11.1%)5 (13.9%)>0.9999
Full NAC necrosis1 (5.6%)2 (5.6%)>0.9999
Minor infection04 (11.1%)0.2888
Major infection1 (5.6%)2 (5.6%)0.9999
Seroma2 (11.1%)1 (2.8%)0.2550
Reconstructive failure03 (8.3%)0.5428
NAC Malposition Correction2 (11.1%)2 (5.6%)0.5963
Follow-up Length (mo)27.346.20.0015
NSM, Nipple-sparing mastectomy; BR, breast reduction; BMI, body mass index; IMF, DIEP, deep inferior epigastric artery perforator flap; inframammary fold; NAC, nipple-areola complex. *Indicates matching criteria.**One case of wise-pattern immediate implant staged reconstruction was not able to be matched by incision type. The nearest similar mastectomy weights were utilized to match the case to non-staged immediate implant reconstructions with IMF incisions and the same remaining matching criteria.†In the staged breast reduction cohort, mastectomy weight is a sum of the breast reduction weight and the mastectomy specimen weight.

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