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Approaches to Microvascular Breast Reconstruction After Total Skin-Sparing Mastectomy

A Comparison of Techniques

Raghavan, Shyam MD*; Peled, Anne Warren MD*; Hansen, Scott L. MD*; Esserman, Laura J. MD, MBA; Sbitany, Hani MD*

doi: 10.1097/SAP.0000000000000391
Clinical Articles

Introduction Preserving the entire breast skin envelope through total skin-sparing mastectomy (TSSM) techniques, in conjunction with immediate autologous reconstruction, can provide excellent aesthetic outcomes for patients. However, postoperative ischemic complications, including nipple-areolar complex (NAC) and skin flap necrosis, can negatively impact reconstructive outcomes. As a strategy for minimizing ischemic complications, we have recently begun performing 2-stage autologous reconstruction after TSSM with immediate tissue expander placement, followed by second-stage microvascular reconstruction, as an alternative to immediate autologous reconstruction.

Methods A prospectively collected database of patients undergoing TSSM and immediate breast reconstruction was reviewed for patients who underwent microvascular reconstruction. Patients were divided into 2 cohorts, those who underwent immediate microvascular reconstruction and those who had a 2-stage procedure. Outcomes for comparison included complication rates and aesthetic outcome scores based on review of postoperative photographs by blinded observers (comprised of plastic surgery attending physicians and residents).

Results During the 2-year study period, there were 21 immediate microvascular reconstructions performed (14 patients) and 16 two-stage reconstructions performed (10 patients). Mean time to completion of reconstruction in the staged cohort was 11.5 months (range, 6.1–21 months). Rates of NAC necrosis were significantly higher in the immediate cohort compared to the staged cohort (29% vs 0%, P = 0.03), which contributed to higher rates of unplanned operative intervention in the immediate cohort (23.8% vs 6.25%, P = 0.14). There were no flap losses in either cohort. Aesthetic scores for NAC color and overall appearance were higher in the staged group compared to the immediate group (P < 0.001 and P = 0.1, respectively), although they were equivalent for nipple position and projection.

Conclusions Two-stage microvascular reconstruction after TSSM is associated with fewer complications and improved NAC aesthetic outcomes compared to immediate autologous reconstruction. Although time to final reconstruction is longer with the staged approach, the aesthetic benefits and reduction in postoperative complications support the use of this approach to optimize outcomes.

From the Divisions of *Plastic and Reconstructive Surgery, and †Breast Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.

Received July 11, 2014, and accepted for publication, after revision, October 17, 2014.

Conflicts of interest and sources of funding: none declared.

Reprints: Hani Sbitany, MD, Division of Plastic Surgery, University of California, San Francisco, 505 Parnassus Ave, Suite M593, San Francisco, CA 94143. E-mail:

Presented at the California Society of Plastic Surgeons Annual Meeting, May 2014, Newport Beach, CA.

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