Delayed-immediate Breast Reconstruction In The Era Of Pre-pectoral Tissue Expanders: An Algorithmic Approach
Haripriya S. Ayyala, MD1, Jerette J. Schultz, MD2, Emmeline Jia, BA3, Rose S. Maisner, BS2, Jeremy Sinkin, MD3, Emily Van Kouwenberg, MD3, Richard L. Agag, MD3.
1Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Rutgers-New Jersey Medical School, Newark, NJ, USA, 3Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Background: Current trends toward pre-pectoral tissue expander placement and nipple sparing mastectomies have decreased the morbidity and improved the cosmetic outcomes for breast reconstruction. The authors aim to delineate an algorithm for patients undergoing autologous breast reconstruction. Methods: A prospectively maintained patient database was queried for all patients undergoing autologous reconstruction. Factors considered in surgical decision-making for reconstruction included type of mastectomy, incision pattern, plan for radiation, pre-operative breast volume and degree of ptosis, and presence of adequate tissue for autologous reconstruction. Breast complication rates were compared between the immediate reconstruction group and the delayed-immediate reconstruction group. Results: 84 patients and 131 breasts underwent autologous breast reconstruction after mastectomy. 62 breasts underwent immediate reconstruction, and 48 breasts underwent delayed-immediate reconstruction. Compared to patients undergoing immediate autologous breast reconstruction, patients undergoing delayed-immediate pre-pectoral reconstruction have a decreased major breast complication rate (32.3% vs 4.2%; p<0.001), mastectomy flap necrosis rate (32.3% vs 0%; p<0.001) and nipple-areolar complex necrosis rate (19.3% vs 0%; p<0.001). Patients with anticipated skin envelope deficiency should undergo immediate reconstruction. Patients undergoing nipple-sparing mastectomy should have delayed-immediate pre-pectoral reconstruction to take advantage of the delay phenomenon for the nipple-areolar complex. Any patients expected to receive post-operative radiation should have delayed-immediate reconstruction. Incisions on the breast should be made within the Wise pattern to preserve breast shape, cosmesis, and facilitate subsequent revision surgery. Conclusions: Pre-pectoral delayed-immediate breast reconstruction results in a decreased major breast complication rate. This algorithm serves as a useful guideline for decision making in autologous breast reconstruction.
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