Mastectomy Incision Types for Immediate Two-Stage Implant Based Breast Reconstruction: Complications Between Vertical and Transverse Patterns
James Butterfield1, Joseph M. Escandón1, Keith Sweitzer1, Jose G Christiano1, Anna C Weiss1, Howard N. Langstein1, Oscar J. Manrique1
1University of Rochester Medical Center, Rochester, NY
Purpose: There is limited literature regarding the incision/excision patterns for breast cancer mastectomy. Some reports by Kraissl proposed horizontal dome-shaped excision lines, while Langer suggested concentric excision lines around the nipple. Despite the contradicting implications of these approaches, and although these incision lines do not consider aging, differences in shape, and the effect of gravity; the presence of vertical incisions are usually avoided as they are situated perpendicular to tension lines. In this setting, we evaluated the rate of complications between vertical and transverse incision patterns during two-stage implant-based breast reconstruction (IBR) after skin-sparing mastectomy (SSM).
Methods: A retrospective review was performed of all consecutive patients undergoing SSM and immediate two-stage IBR from 01/2011-12/2020. According to the classification by Dec et al., modified wise-pattern and circum-vertical incisions were classified as vertical incisions, while fusiform or elliptical peri-areolar incisions were considered as transverse incision patterns. We evaluated the perioperative outcomes between groups.
Results: Two hundred fifty-two patients underwent SSM and immediate 2-stage IBR. Of 415 reconstructive cases, 26.74% of the mastectomies had vertical incision patterns while 73.25% had transverse incision patterns. Most demographic and clinical characteristics were comparable between groups. A higher median mastectomy weight (833-g versus 550-g, p<.001) was reported in the vertical incision pattern group. The vertical incision pattern group had a higher wound-related complication rate (34% versus 16%, p=0.003), flap necrosis rate (25% versus 9%, p <.001), dehiscence rate (15% versus 8%, p=0.034), and rate of excision/debridement and closure (E/D+C) (23% versus 9%, p<.001) during the first stage of IBR when compared to the transverse incision pattern group. On univariate analysis, using vertical incision patterns for mastectomy increased the likelihood of E/D+C for wound-related complications after immediate TE insertion (OR 2.98, 95%CI 1.64–5.41, p<.001). When adjusting for the mastectomy weight and BMI of patients, a vertical incision pattern remained as an independent predictor for the requirement of E/D+C for wound-related complications on multivariate analysis (OR 2.54, 95%CI 1.3–4.95, p=0.006).
Conclusion: When compared to transverse incision patterns, reconstruction closed with vertical incision patterns increased the risk of wound-related complications during the first stage of IBR. Certainly, vertical incision patterns are preferred in large breasts with ptosis. In these cases, a delayed insertion of the TE can improve the safety profile of these types of incision patterns and the outcomes of reconstruction.
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