PERFORATOR FLAP RECONSTRUCTION ALLOWS FULL SECONDARY MASTOPEXY AND NIPPLE REPOSITIONING
Though there are soft clinical contraindications for nipple-sparing mastectomy (NSM), the anatomic contraindications are less well defined. Patients with moderate to severe ptosis are considered by many to be generally poorer candidates for NSM as there is a deemed increase in the risk of nipple necrosis and an impaired ability to reposition the nipple. One strategy reported by Spear et al. is to perform a staged procedure beginning with an initial reduction followed by a delayed NSM. Because the cancer is not removed at the initial stage of this procedure, it applies almost solely to patients having risk-reduction surgery. Others have reported mastopexy at the time of mastectomy. However, this practice requires maintenance of dermal continuity with the skin envelope resulting in limited nipple repositioning and fragile blood supply. In a study by Dellacroce et al. from the Center for Restorative Breast Surgery, it was theorized that the nipple-areola complex (NAC) could be repositioned without necrosis, based solely on the neovascularity of a perforator flap.
Seventy women underwent 116 NSMs. Eighty-four mastectomies were prophylactic, and 32 were therapeutic. The NSMs were generally performed through a 6 o’clock vertical incision though several patients had a lateral incision and a small number an infra-mammary incision. Immediate reconstruction was performed with a DIEP flap and 62 patients and an SGAP (superior gluteal artery perforator flap) in 54. Eight patients had undergone prior lumpectomy, and five of these had received post lumpectomy radiation. One patient had undergone prior mastopexy with a Wise pattern incisional design. In the image below, one can see that the skin around the reduced NAC is de-epithelialized. The skin envelope is then elevated over the perforator flap, and the shape and size are modified as desired.
Breast-related complications occurred in 16 cases. There were nine partial incisional dehiscences, partial skin-flap necrosis in four patients, and three hematomas requiring operative intervention. There were no flap failures. After surgical débridement and or wound care, all mastectomy flap wounds healed successfully. Examples of the final cosmetic results appear below.
The authors noted that patients with breast cancer who present with significant breast ptosis results in a significant dilemma for the reconstructive surgeon. Once NSM is performed, the blood supply to the NAC depends on capillary flow in the skin and dermis. Any profusion from the underlying breast is eliminated. This study shows “that it is possible to safely create a full-thickness, complete periareola incision with wide-field peripheral skin undermining around a preserved NAC after NSM without nipple necrosis. Because of robust NAC revascularization, it is possible to completely reposition the preserved NAC in a manner differing very little from a routine mastopexy.” Furthermore, the authors note that this removes any contraindication, even grade III ptosis, from the selection criteria in patients desiring NSM who have been diagnosed with breast cancer.