A Novel Ratio for Optimizing Tissue Expander Fill and Minimizing Nipple Areolar Complex Complications in Prepectoral Breast Reconstruction
Sofia Perez Otero*1, Kshipra Hemal2, Carter J. Boyd2, Raeesa Kabir1, Jamie P. Levine2, Oriana Cohen2, Vishal Thanik2, Nolan S. Karp2, Mihye Choi2
1Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, NYU Langone Health, New York, NY; 2Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
This study assesses the risk factors contributing to Nipple Areolar Complex (NAC) necrosis after prepectoral tissue expander (TE) reconstruction, and identifies strategies for mitigating this risk.
All consecutive, prepectoral TE reconstructions performed between 03/2017 - 07/2022 at a single center were reviewed. A ratio of intraoperative TE fill to mastectomy weight (TEF/MW) was constructed to quantify "deadspace" in the breast pocket, with values closer to 1 signifying less deadspace. Partial NAC necrosis was defined as any thickness skin loss including part of the NAC, while total NAC necrosis was defined as full-thickness skin loss of the entire NAC. p<0.05 was considered statistically significant.
A total of 184 patients (292 breasts) were included, with average follow up of 27 months. Women were on average 53 years old, non-smoker (99%), non-diabetic (91%), and had a body mass index (BMI) of 28 kg/m2. Reconstructions were performed immediately after prophylactic mastectomies in 33% and therapeutic mastectomies in 67% of cases. Mastectomies were mostly skin sparing (61%), followed by nipple sparing (24%) and simple (12%). Median mastectomy weight was 551grams, average intraoperative TE fill was 194163cc, and average final TE fill was 416159cc.
Partial NAC necrosis occurred in 3% of breasts and complete NAC necrosis in 0. Partial NAC necrosis was associated with lower BMI, lower mastectomy weight, and less deadspace. Optimal intraoperative TEF/MW ratio for avoiding partial NAC necrosis was 0.31. In multivariable models, partial NAC necrosis was associated with lower BMI. For every 1-point increase in BMI, the odds of partial NAC necrosis decreased by 0.67 (95% CI [0.42-1.0], p=0.05).
Lower BMI patients had higher odds of partial NAC necrosis following prepectoral TE reconstruction. Potential strategies for mitigating risk of NAC necrosis include optimizing the intraoperative TEF/MW ratio to one-third.
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