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Immediate Breast Reconstruction Following Total Skin-Sparing Mastectomy: Outcomes and Predictors of Reconstructive Complications over 9 Years
Frederick Wang, M.D., Anne Warren Peled, M.D., Michael Alvarado, M.D., Cheryl Ewing, M.D., Laura Esserman, M.D., M.B.A., William Hoffman, M.D., Robert Foster, M.D., Hani Sbitany, M.D..
University of California, San Francisco, San Francisco, CA, USA.

PURPOSE:
Total skin-sparing mastectomy (TSSM), with complete preservation of the nipple-areola complex skin, has become increasingly accepted and offered to women for both prophylactic and therapeutic indications. We examined risk factors for postoperative complications and reconstructive failure.
METHODS:
This is a retrospective study of TSSM cases performed from January 2005 to December 2013. Outcome measures included nipple necrosis, postoperative infections, and implant loss. Logistic generalized estimating equation models were used to evaluate risk factors for postoperative complications.
RESULTS:
We performed 1140 TSSM cases in 727 patients with median follow-up time of 24 months. Of these, 1045 (92%) were 2-stage tissue expander-based reconstructions followed by implant or autologous flap, and 95 (8%) were immediate autologous flap or implant reconstructions. There were 42 (3.7%) cases of partial or complete nipple necrosis, and significant risk factors included prior radiation, immediate autologous or implant reconstruction, and incision location. Postoperative infections occurred in 226 (19%) cases, and significant risk factors included prior or post-mastectomy radiation. Of the tissue expander-based reconstructions, 79 (7.6%) were lost, and significant risk factors included smoking history and radiation therapy. In cases with post-mastectomy radiation, both acellular dermal matrix (ADM)-assisted (OR 0.2, 95% CI 0.1-0.9) and serratus flap (OR 0.1, 95% CI 0.0-0.7) coverage decreased the risk of implant loss.
CONCLUSION:
We identified significant risk factors for partial or complete nipple necrosis, infections, and implant loss after TSSM. In cases of tissue expander-based reconstruction that undergo post-mastectomy radiation, ADM-assisted and serratus flap coverage of tissue expanders both protect against implant loss.


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