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Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

Frey, Jordan, D., M.D.; Stranix, John, T., M.D.; Chiodo, Michael, V., M.D.; Alperovich, Michael, M.D.; Ahn, Christina, Y., M.D.; Allen, Robert, J., M.D.; Choi, Mihye, M.D.; Karp, Nolan, S., M.D.; Levine, Jamie, P., M.D.

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 1086–1093
doi: 10.1097/PRS.0000000000004271
Breast: Original Articles

Background: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle.

Methods: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring.

Results: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296).

Conclusion: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors’ technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

New York, N.Y.; and New Haven, Conn.

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center; and the Section of Plastic Surgery, Yale School of Medicine.

Received for publication February 23, 2017; accepted November 8, 2017.

The first two authors should be considered co–first authors.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Jamie P. Levine, M.D., Department of Plastic Surgery, New York University Langone Medical Center, 550 First Avenue, New York, N.Y. 10016, jamie.levine@nyumc.org

©2018American Society of Plastic Surgeons