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Comparison Of Surgical And Clinical Outcomes In Abdominal Free Flap-Based Breast Reconstruction After Nipple-Sparing Mastectomy Versus Skin-sparing Mastectomy With Nipple-Areolar Complex Reconstruction
Joan Lee, AB1, Cagri Cakmakoglu, MD2, Isis Scomacao, MD2, Humzah Quereshy, BS1, Andrea Moreira, MD2, Risal Djohan, MD2, Steven Bernard, MD2, Eliana Duraes, MD2, Graham Schwarz, MD2.
1Case Western Reserve University, Cleveland, OH, USA, 2Cleveland Clinic, Department of Plastic Surgery, Cleveland, OH, USA.

Purpose:
Autologous breast reconstruction that is performed in conjunction with nipple-sparing mastectomy (NSM) has garnered attention in recent years as a surgical approach that, in appropriate patients, could provide optimal postmastectomy cosmesis as a single-stage procedure. However, the risks of morbidities that accompany nipple preservation remain under investigation. This study examined complication rates of abdominal free flap-based breast reconstructions that were performed with NSM or with skin-sparing mastectomy (SSM) followed by nipple reconstruction.
Methods:
Retrospective chart review was conducted to identify patients who underwent NSM and abdominal free flap-based breast reconstruction and patients who underwent SSM, abdominal free flap-based breast reconstruction, and nipple reconstruction from 2006 to 2018 at a single institution. Demographics and outcomes were recorded. Breast-related complications rates were calculated per breast, while donor site and clinical complication rates were calculated per patient. Statistical analysis was conducted using an unpaired two-tailed t test.
Results:
202 NSMs with abdominal free flap-based reconstruction (121 patients) and 203 SSMs with abdominal free flap-based reconstruction and nipple reconstruction (119 patients) were included. The majority of reconstructions (88% NSM, 92% SSM) employed a DIEP flap.
Breast complications in the 30 days following reconstruction were generally more prevalent in the NSM group (wound dehiscence, 20.6% vs 4%; delayed wound healing, 17.6% vs 7.4%; nipple-related complications, 16% vs 1%). Skin necrosis occurred in 28.6% of SSM reconstructions and 27.5% of NSM reconstructions. Donor site complications occurred in 9.9% of NSM patients and 8.6% of SSM patients.
The mean number of revision surgeries was significantly greater in the SSM group (1.67 [s.d. 0.82] vs 1.24 [0.93], p < .01). Donor site revisions (59% NSM, 60% SSM), breast fat grafting (51.8% NSM, 46% SSM), breast scar revision (49% NSM, 12% SSM), and skin paddle removal (46% NSM, 20% SSM) were the most common revision procedures. All SSM patients underwent a revision that included nipple reconstruction. 7% of the NSM group eventually required nipple reconstruction. The most prevalent revision-stage complication was skin necrosis (4.5% SSM, 1.8% NSM). The SSM group had a greater rate of complications that required reoperation during the revision stage (4% vs 0.5%).
SSM patients had more days of surgical admission (3 [2.31] vs 2.09 [1.8800], p < .01) during the first reconstruction attempt. The mean number of total surgeries did not differ significantly (3.02 [1.08] vs 2.76 [1.6], p > .1). However, NSM reconstructions were followed by a greater mean number of reoperations for complications (0.7 [1.08] vs 0.24 [0.5], p<.01).
Conclusions:
This study provided a single-institution perspective on surgical complication rates of breast reconstruction using abdominal free flap after NSM or SSM with nipple reconstruction. Future studies may seek to identify predictors of breast complications in reconstructions following NSM
through matched cohort studies and multivariate analyses, as well as analyze aesthetic ratings and patient-reported satisfaction outcomes.


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