Implant-based reconstructions are the most common form of postmastectomy reconstruction. Mastectomy flap necrosis is a dreaded complication leading to poor outcomes and patient dissatisfaction. The correct surgical technique when performing mastectomy flap elevation is a key factor in flap viability. Mastectomy flaps are random dermal flaps; therefore, in addition to anatomically correct flap dissection and elevation, a favorable flap length-to-base ratio is of great importance. Traditional mastectomy incisions used a simple elliptical excision of the central breast skin, including the nipple-areolar complex, and resulted in broad-based and short mastectomy flaps or random dermal flaps; therefore, in addition to anatomically correct flap dissection and elevation, a favorable flap length-to-base ratio is of great importance. Traditional mastectomy incisions used a simple elliptical excision of the central breast skin, including the nipple-areolar complex, and resulted in broad-based and short mastectomy flaps. Over the last 20 years, skin-sparing mastectomies, as well as complete skin-sparing nipple-sparing mastectomies with immediate reconstruction, have gained popularity. Preserving all or most of the skin envelope resulted in much longer mastectomy flaps. Additionally, the mastectomy flaps now also include the central breast skin with its extreme paucity of subcutaneous fat as well as the nipple-areolar complex with a complete absence of subcutaneous fat, and a merge of the ductal parenchyma with the dermal plane. These long and central breast areas, very thin flaps, were now used to cover the prosthetic devices. This resulted in double-digit reports of mastectomy skin necrosis, as well as increased rates of infections, seromas, implant loss, reoperations, and poor patient outcomes. We describe a simple modification of the mastectomy skin envelope, which allows for the recruitment of thicker chest wall skin over the implants, a shortening of overall mastectomy flap length, and a doubling up of soft tissue in the lower implant pocket by using a de-epithelialized dermal flap. Nipple-sparing procedures are achieved by grafting the nipple-areolar complex as a full-thickness graft onto the correct anatomical position on the mastectomy.
A retrospective chart review was performed of all patients who underwent wise pattern modification of their mastectomy flaps and implant-based reconstructions from 2010 to 2022 by the first author. Demographic, clinical, and operative data were recorded. Outcomes were assessed by evaluation of surgical complication rates, including mastectomy flap necrosis, seroma, hematoma infection, capsular contracture, and implant loss.
Nine-hundred-and-four wise pattern mastectomies were performed in 509 patients with a mean age of 52.5 years and a mean body mass index of 28.8. In the cohort, 28 (3.3%) patients were active smokers, 30 were diabetic (5%), and 135 (14.5%) mastectomies underwent chest wall radiation. Complication rates compared favorably to published data of non–wise pattern mastectomies with implant-based reconstructions. We encountered major mastectomy flap necrosis in 15 breasts (1.6%), capsular contracture in 57 patients (6.3%), major infection in 21 breasts (2.3%), implant loss in 26 breasts (2.8%), seroma in 3 breasts (0.3%), and hematoma in 5 breasts (0.5%) of reconstructed breasts. Major infections were the leading cause of temporary or permanent implant loss. All capsular contractures occurred in radiated patients.
The results of this large cohort study of mastectomy reconstructions over 12 years with a modified mastectomy skin envelope to optimize mastectomy flap viability in immediate implant-based reconstructions show that overall complication rates are reduced compared to data published in the literature. While clinical results are encouraging, further anatomical studies on the vasculature and soft tissue thickness of the modified versus traditional flaps are needed.
Anke Ott Young,1,2,3 Christine Hody,1,3 Melanie Lynch,1 Amit Elazar,3 Sravya Chilukuri,3 Lillian Huang,3 Rheda Young,4 Tomasso Addona,2 Mary Pronovost5
1Yale New Haven Health, New Haven, CT.
2New York Plastic Surgery Group, New York, NY.
3Mount Sinai South Nassau, Oceanside, NY.
4Schule Schloss Salem, Salem, Germany.
5Lewis Katz School of Medicine, Philadelphia, PA.