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Assessing and Revising Surgical Technique to Improve Outcomes after Total Skin-Sparing Mastectomy: Results from 707 Cases
Anne Warren Peled, MD1, Robert D. Foster, MD1, Cheryl Ewing, MD1, Michael Alvarado, MD1, E. Shelley Hwang, MD, MPH2, Laura J. Esserman, MD, MBA1.
1University of California, San Francisco, San Francisco, CA, USA, 2Duke University Medical Center, Durham, NC, USA.

Assessing and revising surgical technique to improve outcomes after total skin-sparing mastectomy: results from 707 cases
Purpose:
Total skin-sparing mastectomy (TSSM) with complete preservation of the breast skin envelope including the nipple-areolar complex is becoming increasingly accepted as a means of providing improved aesthetic outcomes for patients. However, many centers are still hesitant to perform the procedure due to concern for oncologic safety, the technical difficulty of performing the cases, and potentially higher post-operative complication rates.
Methods:
Review of a prospectively maintained database containing outcomes from all patients who underwent TSSM with immediate reconstruction from 2001-2011 was performed, which identified 707 TSSM procedures in 452 patients. Post-operative complication rates in different cohorts defined by mastectomy technique and reconstructive characteristics were compared using chi-square analysis.
Results:
Prophylactic mastectomies accounted for 265 (37.4%) of the cases, with the rest performed for therapeutic indications. Mean follow-up was 27.6 months (range 3 - 115 months). Two-stage expander-implant reconstruction accounted for the majority (82.3%) of cases, with the rest comprised of pedicled TRAM flap (8.8%), microvascular (4.2%), and permanent implant (4.2%) reconstructions. Ischemic or necrotic post-operative complications included 13 cases (1.8%) of partial nipple loss, 10 cases (1.4%) of complete nipple loss, and 83 cases (11.7%) of skin flap necrosis or incisional dehiscence. Rates of partial or complete nipple loss were significantly higher in cases of autologous reconstruction (14 of 79 cases, 17.7%) compared to prosthetic reconstruction (9 of 612 cases, 1.5%; p < 0.0001), as were rates of skin flap necrosis (32.9% vs. 9.3%, p < 0.0001). Targeted modifications in mastectomy and reconstructive techniques during our early experience led to a shift away from autologous or immediate implant reconstruction towards tissue expander reconstruction with minimal initial fill volume (28% in the first 100 cases compared to 92.3% in the next 607 cases, p < 0.0001) as well as a shift away from incisions encompassing more than 30% of the nipple-areolar complex (24% in the first 100 cases compared to 0.8% in the next 607 cases, p < 0.0001). These technical modifications were associated with a significant improvement in nipple-related complications over time, with rates of partial or complete nipple loss decreasing from 13% in the first 100 cases to 1.5% in the rest of the cases (p < 0.0001).
Conclusions:
Outcomes from this large series of total skin-sparing mastectomy and immediate reconstruction demonstrate that the technique can be safely performed with low rates of associated ischemic complications once the technical factors that lead to skin and nipple necrosis are recognized and avoided. In our experience, outcomes can be optimized through minimizing pressure on mastectomy skin flaps and the nipple-areolar complex with the use of tissue expander reconstruction with minimal initial fill volume and through minimizing the extent of the nipple-areolar component of TSSM incisions.


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