Buried flap reconstruction after nipple-sparing mastectomy: advancing toward single-stage breast reconstruction.

Overview

abstract

BACKGROUND: Recent evolutions of oncologic breast surgery and reconstruction now allow surgeons to offer the appropriate patients a single-stage, autologous tissue reconstruction with the least donor-site morbidity. The authors present their series of buried free flaps in nipple-sparing mastectomies as proof of concept, and to explore indications, techniques, and early outcomes from their series. METHODS: From 2001 to 2011, a total of 2262 perforator-based free flaps for breast reconstruction were reviewed from the authors' prospectively maintained database. RESULTS: There were 338 free flaps performed on 215 patients following nipple-sparing mastectomy, including 84 patients who underwent breast reconstruction with 134 buried free flaps. Ductal carcinoma in situ and BRCA-positive were the most common diagnoses, in 26 patients (30.9 percent) each. The most common flaps used were the deep inferior epigastric perforator (77.6 percent), transverse upper gracilis (7.5 percent), profunda artery perforator (7.5 percent), and superficial inferior epigastric artery flaps (3.7 percent). An implantable Cook-Swartz Doppler was used to monitor all buried flaps. Fat necrosis requiring excision was present in 5.2 percent of breast reconstructions, and there were three flap losses (2.2 percent). Seventy-eight flaps (58.2 percent) underwent minor revision for improved cosmesis; 56 (41.8 percent) needed no further surgery. CONCLUSIONS: Nipple-sparing mastectomy with immediate autologous breast reconstruction can successfully and safely be performed in a single stage; however, the authors are not yet ready to offer this as their standard of care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.