Ischemic Complications after Nipple-sparing Mastectomy: Predictors of Reconstructive Failure in Implant-based Reconstruction and Implications for Decision-making

Abstract

Background: Mastectomy flap and nipple–areola complex (NAC) ischemia can be devastating complications after nipple-sparing mastectomy (NSM). Predictors of reconstructive failure with major skin envelope ischemia and implications for decision-making remain to be fully elucidated. Methods: All cases of implant-based reconstruction after NSM from 2006 to June 2018 with mastectomy flap necrosis or NAC necrosis requiring debridement were reviewed. Data on patient demographics, operative characteristics, additional complications, and the nature and management of ischemic complications were collected and analyzed. Results: Out of 1045 NSMs, 70 cases (6.7%) had major ischemic complications. Fifty-two cases (74.3% of major ischemic complications) had isolated major mastectomy flap necrosis, 7 (10%) had full NAC necrosis and 11 (15.7%) had both. Five cases (7.1%) underwent implant exchange at the time of debridement and 15 cases (21.4%) required explantation. Explanted cases had significantly lower body mass index (22.3 versus 24.7, P = 0.013) and larger debridement size (49.5 cm 2 versus 17.6 cm 2 , P = 0.0168). Additionally, explanted cases had a higher rate of acellular dermal matrix/mesh (100% versus 45.5%, P < 0.0001), prior radiation (20.0% versus 0%, P = 0.0083), immediate implants (46.7% versus 20.0%, P = 0.0491), major infection (30.0% versus 1.8%, P = 0.028), and both major mastectomy flap/NAC necrosis (33.3% versus 10.9%, P = 0.0494). Conclusions: NSM cases with major ischemia requiring explantation had a lower body mass index and significantly higher rate of preoperative radiation, immediate implant placement, use of acellular dermal matrix/mesh, and concomitant major infection. These variables should be taken into account when discussing risks with patients preoperatively and assessing the quality of mastectomy flaps and subsequent reconstructive choices intraoperatively.

Picking the Right Plane: A Comparison of Total Submuscular, Dual-Plane, and Prepectoral Implant-based Breast Reconstruction

“…Although long-term outcomes such as capsular contracture rates are unknown with this approach, the trend has been inspired largely by increased confidence in the ability of the tabs to maintain expander position and relieve pressure on the mastectomy flaps from the weight of the expander, the high cost associated with the use of acellular dermal matrix, and previous experience in a cohort of patients who underwent nipple-sparing mastectomy showing greater rates of explantation in those who received acellular dermal matrix compared with those who did not. 40…”

“…As a further point regarding dual-plane reconstruction, which in this study still had a significantly higher rate of explantation compared with total submuscular prosthesis placement, one must consider that implant coverage with acellular dermal matrix is not equivalent to total submuscular coverage, and acellular dermal matrix exposure must be treated as akin to implant exposure. 40,43…”

“…The implication of preoperative radiation in failure of implant-based breast reconstruction has previously been suggested by Salibian and colleagues in a 2019 article exploring factors associated with major ischemic complications and explantation after nipple-sparing mastectomy. 40 Explantation has been both directly and indirectly associated with body mass index. In 2018, Ozturk et al 41 found that tissue expander removal was significantly more likely to occur in patients with a higher body mass index; Frey and colleagues 37 reported explantation as occurring more frequently in patients with larger breast size, which is often thought not to be exclusively associated with higher body mass index.…”

“…Plastic and Reconstructive Surgery • October 2022 approach, the trend has been inspired largely by increased confidence in the ability of the tabs to maintain expander position and relieve pressure on the mastectomy flaps from the weight of the expander, the high cost associated with the use of acellular dermal matrix, and previous experience in a cohort of patients who underwent nipple-sparing mastectomy showing greater rates of explantation in those who received acellular dermal matrix compared with those who did not. 40 The most striking difference in postoperative outcomes among the total submuscular, dual-plane, and prepectoral groups was their rates of explantation, which were 1.8 percent, 6.1 percent, and 10.5 percent, respectively. The final multivariable regression model comparing the total submuscular and prepectoral groups suggested prepectoral implant placement, preoperative radiation, and increased body mass index as factors that increased risk of explantation in prepectoral breast reconstruction.…”

Breast Reconstruction After Mastectomy: A Systematic Review and Meta-Analysis

“…Among the five single group studies, one assessed IBR and four AR (Appendix Table F-1.26). In the IBR study (Salibian 2019), major ischemic complications occurred in 6.7 percent of patients at 3.3 years of followup. In the four AR studies, the risk of overall complications at 9 years of followup was 19.3 percent (1 study), the risk of wound problems at 9 to 10 months of followup was 12.6 percent (1 study), the risk of breast seroma, hematoma, or wound infection at 5 years of followup was 3.4 percent (1 study), and the risk of deep vein thrombosis, pulmonary embolism, myocardial infarction and others was 6.4 percent (1 study).…”