Nipple-sparing mastectomy with immediate breast reconstruction with a deep inferior epigastric perforator flap without skin paddle using delayed primary retention suture
Eamon C. Francis MD, MCh, MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
Search for more papers by this authorEleonora O. F. Dimovska MBBS, MRCS, MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
Search for more papers by this authorHsu-Huan Chou MD
Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Search for more papers by this authorYi-Ling Lin MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Search for more papers by this authorCorresponding Author
Ming-Huei Cheng MD, MBA, FACS
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
Correspondence Ming-Huei Cheng, MD, MBA, FACS, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5, Fu-Hsing St, Kueishan, Taoyuan 33305, Taiwan.
Email: [email protected]
Search for more papers by this authorEamon C. Francis MD, MCh, MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
Search for more papers by this authorEleonora O. F. Dimovska MBBS, MRCS, MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
Search for more papers by this authorHsu-Huan Chou MD
Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Search for more papers by this authorYi-Ling Lin MSc
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Search for more papers by this authorCorresponding Author
Ming-Huei Cheng MD, MBA, FACS
Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
Correspondence Ming-Huei Cheng, MD, MBA, FACS, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5, Fu-Hsing St, Kueishan, Taoyuan 33305, Taiwan.
Email: [email protected]
Search for more papers by this authorAbstract
Background
This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics.
Methods
Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups.
Results
Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 months of follow-up, the Breast-Q “Satisfaction with surgeon” domain was significant in Group B (p = 0.04). At a mean 12 months of follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04).
Conclusions
The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
Open Research
DATA AVAILABILITY STATEMENT
For accessing the original data, please contact Yi-Ling Lin, MSc at [email protected].
Supporting Information
| Filename | Description |
|---|---|
| jso26852-sup-0001-DPRS_Video_MHC_210606a.mp415.2 MB | Supplement Video clip 1. Closed wound with delayed primary retention suture in the nipple-sparing mastectomy with immediate reconstruction with a deep inferior epigastric perforator flap. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Burdge EC, Yuen J, Hardee M, et al. Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol. 2013; 20(10): 3294-3302.
- 2Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013; 20(10): 3218-3222.
- 3Frey JD, Alperovich M, Kim JC, et al. Oncologic outcomes after nipple-sparing mastectomy: a single-institution experience. J Surg Oncol. 2016; 113(1): 8-11.
- 4Peled AW, Wang F, Foster RD, et al. Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease? Ann Surg Oncol. 2016; 23(1): 87-91.
- 5Seki T, Jinno H, Okabayashi K, et al. Comparison of oncological safety between nipple sparing mastectomy and total mastectomy using propensity score matching. Ann R Coll Surg Engl. 2015; 97(4): 291-297.
- 6Spear SL, Shuck J, Hannan L, Albino F, Patel KM. Evaluating long-term outcomes following nipple-sparing mastectomy and reconstruction in the irradiated breast. Plast Reconstr Surg. 2014; 133(5): 605e-614e.
- 7Rodriguez-Feliz J, Codner MA. Embrace the change: incorporating single-stage implant breast reconstruction into your practice. Plast Reconstr Surg. 2015; 136(2): 221-231.
- 8Fujimoto H, Ishikawa T, Satake T, et al. Donor site selection and clinical outcomes of nipple-areola skin-sparing mastectomy with immediate autologous free flap reconstruction: a single-institution experience. Eur J Surg Oncol. 2016; 42(3): 369-375.
- 9Tanna N, Broer PN, Weichman KE, et al. Microsurgical breast reconstruction for nipple-sparing mastectomy. Plast Reconstr Surg. 2013; 131(2): 139e-147e.
- 10Ho OA, Lin YL, Pappalardo M, Cheng MH. Nipple-sparing mastectomy and breast reconstruction with a deep inferior epigastric perforator flap using thoracodorsal recipient vessels and a low lateral incision. J Surg Oncol. 2018; 118(4): 621-629.
- 11Laporta R, Longo B, Sorotos M, Pagnoni M, Santanelli Di Pompeo F. DIEP flap sentinel skin paddle positioning algorithm. Microsurgery. 2015; 35(2): 91-100.
- 12Koolen PGL, Vargas CR, Ho OA, et al. Does increased experience with tissue oximetry monitoring in microsurgical breast reconstruction lead to decreased flap loss? The learning effect. Plast Reconstr Surg. 2016; 137(4): 1093-1101.
- 13Konczalik W, Nikkhah D, Mosahebi A. Applications of smartphone thermal camera imaging system in monitoring of the deep inferior epigastric perforator flap for breast reconstruction. Microsurgery. 2017; 37(5): 457-458.
- 14Chang EI, Ibrahim A, Zhang H, et al. Deciphering the sensitivity and specificity of the implantable Doppler probe in free flap monitoring. Plast Reconstr Surg. 2016; 137(3): 971-976.
- 15Engel H, Huang JJ, Tsao CK, et al. Remote real-time monitoring of free flaps via smartphone photography and 3G wireless Internet: a prospective study evidencing diagnostic accuracy. Microsurgery. 2011; 31(8): 589-595.
- 16Ozturk CN, Ozturk C, Ledinh W, et al. Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction. Microsurgery. 2015; 35(2): 123-128.
- 17Levine SM, Snider C, Gerald G, et al. Buried flap reconstruction after nipple-sparing mastectomy: advancing toward single-stage breast reconstruction. Plast Reconstr Surg. 2013; 132(4): 489e-497e.
- 18Frost MW, Niumsawatt V, Rozen WM, Eschen GE, Damsgaard TE, Kiil BJ. Direct comparison of postoperative monitoring of free flaps with microdialysis, implantable Cook-Swartz Doppler probe, and clinical monitoring in 20 consecutive patients. Microsurgery. 2015; 35(4): 262-271.
- 19Oni G, Saint-Cyr M, Maia M, Colohan S, Rohrich RJ. Secondary techniques in breast reconstruction refinement: the periareolar advancement flap. Plast Reconstr Surg. 2011; 128(5): 1015-1024.
- 20Enajat M, Smit JM, Rozen WM, et al. Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent. Aesthetic Plast Surg. 2010; 34(3): 306-312.
- 21Koide S, Lin CY, Cheng MH. Delayed primary retention suture for inset of vascularized submental lymph node flap for lower extremity lymphedema. J Surg Oncol. 2020; 121(1): 138-143.
- 22Cheng MH, Robles JA, Ulusal BG, Wei FC. Reliability of zone IV in the deep inferior epigastric perforator flap: a single center's experience with 74 cases. Breast. 2006; 15(2): 158-166.
- 23Cheng MH, Lin JY, Ulusal BG, Wei FC. Comparisons of resource costs and success rates between immediate and delayed breast reconstruction using DIEP or SIEA flaps under a well-controlled clinical trial. Plast Reconstr Surg. 2006; 117(7): 2139-2142.
- 24Ali R, Bernier C, Lin YT, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg. 2010; 65(4): 398-406.
- 25Huang JJ, Chao LF, Wu CW, Nguyen DH, Valerio IL, Cheng MH. Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps. Plast Reconstr Surg. 2011; 128(6): 593e-604e.
- 26Lee KT, Pyon JK, Bang SI, Lee JE, Nam SJ, Mun GH. Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy? J Plast Reconstr Aesthet Surg. 2013; 66(11): 1543-1550.
- 27Chen KT, Mardini S, Chuang DCC, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007; 120(1): 187-195.
- 28Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014; 133(3): 496-506.
- 29Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg. 1999; 104(1): 97-101.
- 30Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery. 2010; 30(2): 105-110.
- 31Chae MP, Rozen WM, Whitaker IS, et al. Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg. 2015; 74(5): 621-632.
- 32Paprottka FJ, Klimas D, Krezdorn N, Schlarb D, Trevatt AEJ, Hebebrand D. Cook-Swartz Doppler probe surveillance for free flaps-defining pros and cons. Surg J. 2020; 6(1): e42-e46.
- 33Whitaker I, Rozen W, Chubb D, et al. Postoperative monitoring of free flaps in autologous breast reconstruction: a multicenter comparison of 398 flaps using clinical monitoring, microdialysis, and the implantable Doppler probe. J Reconstr Microsurg. 2010; 26(6): 409-416.
- 34Paydar KZ, Hansen SL, Chang DS, Hoffman WY, Leon P. Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate. Plast Reconstr Surg. 2010; 125(4): 1129-1134.
- 35O'Neill AC, Mughal M, Saggaf MM, Wisniewski A, Zhong T, Hofer SOP. A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications. J Plast Reconstr Aesthet Surg. 2020; 73(1): 19-26.
- 36Frey JD, Salibian AA, Karp NS, Choi M. Examining length of hospital stay after microsurgical breast reconstruction: evaluation in a case-control study. Plast Reconstr Surg Glob Open. 2017; 5(12):e1588.
