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Does Staged Breast Reduction before Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques

Salibian, Ara A. M.D.; Frey, Jordan D. M.D.; Karp, Nolan S. M.D.; Choi, Mihye M.D.

Plastic and Reconstructive Surgery: November 2019 - Volume 144 - Issue 5 - p 1023-1032
doi: 10.1097/PRS.0000000000006121
Breast: Original Articles
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Background: Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking.

Methods: A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes.

Results: Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort.

Conclusion: In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications.


New York, N.Y.

From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health.

Received for publication September 9, 2018; accepted February 5, 2019.

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Presented at Plastic Surgery The Meeting 2018, Annual Meeting of the American Society of Plastic Surgeons, in Chicago, Illinois, September 28 through October 1, 2018.

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

Mihye Choi, M.D., Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 305 East 47th Street, Suite 1A, New York, N.Y. 10017,

As indications for nipple-sparing mastectomy expand,1,2 plastic surgeons must more frequently determine appropriate candidates for nipple-sparing mastectomy based on relative reconstructive contraindications instead of absolute oncologic ones. Studies have demonstrated high patient satisfaction, improved quality of life,3,4 and low complication rates after nipple-sparing mastectomy and breast reconstruction.5 In the ideal candidate for nipple-sparing mastectomy, these outcomes can be reliably and reproducibly obtained. However, as indications for nipple-sparing mastectomy continue to develop, it becomes pertinent to address how to optimize the nonideal candidate to determine whether nipple-sparing options can be safely offered.

Several risk factors for complications after nipple-sparing mastectomy have been described.6–9 A less well-studied but arguably equally important factor is breast morphology, which has a significant impact on reconstructive outcomes. Increasing breast volume,10 mastectomy weight,9 and degree of breast ptosis5 have been correlated with an increased risk of postoperative complications, particularly ischemic events of the mastectomy skin envelope. In addition, elevation of the nipple-areola complex at the time of mastectomy can be challenging in patients with severe ptosis. These concerns regarding poor reconstructive and aesthetic outcomes have led severe macromastia and breast ptosis to often be considered as relative contraindications for nipple-sparing techniques.

Staged breast reduction before nipple-sparing mastectomy has been used as a means of reducing the skin envelope, repositioning the nipple-areola complex, and serving as a vascular delay for the nipple-areola complex and mastectomy flaps.11 For certain patients in whom morphologic factors are the only relative barrier to nipple-sparing mastectomy, such as young high-risk women undergoing prophylactic mastectomy,12 these alternative options can be particularly useful in increasing the likelihood of preserving the nipple-areola complex and minimizing complications.

Prior studies on staged reductions before nipple-sparing mastectomy have shown promising outcomes.13 However, there is a lack of comparative data in the literature between staged and nonstaged techniques. As many variables can influence ischemic complications, the use of historical controls based on comparisons of single series is particularly challenging in justifying the superiority of one technique.

The purpose of this study was to better understand the efficacy of staged reduction in decreasing postoperative complications after nipple-sparing mastectomy in patients with large, ptotic breasts by directly comparing staged cases to matched nonstaged cases with similar risk factors. Clarifying the potential of staging to decrease complications will allow surgeons to more accurately select appropriate candidates for nipple-sparing mastectomy while potentially offering a safer procedure for select patients.

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Patient Selection and Operative Technique

Nipple-sparing mastectomy was discussed as an option with all women undergoing prophylactic mastectomy and oncologically eligible patients undergoing therapeutic mastectomy. All nipple-sparing mastectomy reconstructions were performed using implant-based single or two-stage total submuscular or dual-plane techniques or with autologous microvascular tissue transfer. Mastectomy flaps were evaluated intraoperatively based on clinical assessment of dermis exposure, capillary refill, skin/nipple-areola complex color, and skin-edge bleeding given the routine use of local anesthetic with epinephrine-containing solutions. Details of absolute and relative contraindications for nipple-sparing mastectomy and operative techniques are as described previously.8

Staged reduction was offered to all patients undergoing prophylactic mastectomy who had severe macromastia with at least grade II ptosis. Reduction was planned for anywhere from 3 to 6 months before mastectomy as determined by patient preferences, postoperative recovery, and coordination with oncologic surgeons. Skin incision patterns and pedicle choices were based on individual surgeon preference. A medial or superomedial pedicle is typically preferred to preserve the subcutaneous internal mammary perforators from the second and third intercostal interspaces. Mastectomy incisions were planned to use either a portion or all of the prior reduction incisions in coordination with oncologic surgeons. Intraoperative mastectomy flap evaluation is based on clinical examination of skin and nipple-sparing mastectomy perfusion, skin-edge bleeding, flap thickness, and amount of visible dermis. Indocyanine green angiography is not routinely used given the use of epinephrine-containing local anesthetic before mastectomy.

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Data Analysis

A retrospective review was performed of all patients undergoing nipple-sparing mastectomy at a single institution from 2006 to 2017. Patients who underwent staged bilateral breast reduction in preparation for nipple-sparing mastectomy were identified for inclusion in the study. Data on skin excision pattern, pedicle, reduction specimen weight, and length of time between reduction and nipple-sparing mastectomy were collected and analyzed.

Each staged nipple-sparing mastectomy case (breast) was subsequently matched with two nonstaged cases. A fixed selection procedure was used to identify the best match in which the reviewer was blinded to outcomes. Matching criteria were developed based on well-known risk factors for reconstructive complications in this patient population that overlap with prior studies including certain categorical variables (i.e., mastectomy indication, incision pattern, reconstruction type, radiation history, and active tobacco use)6–8 and a continuous variable (i.e., mastectomy weight).9 Matching was performed by first identifying all nonstaged cases with the same categorical matching criteria. Two nonstaged cases were then selected based on the nearest higher and lower mastectomy weight values for each staged case (Fig. 1). If there was more than one case that was a match for mastectomy weight, the appropriate match was chosen randomly. Mastectomy weight, as an independent predictor of complications,9 served as a quantifiable surrogate for breast size instead of, for example, body mass index or bra size, and was calculated as a combined weight for the staged group based on the sum of the breast reduction specimen weight and mastectomy weight. Combined weight was used for matching to most accurately reflect similar preoperative breast sizes between the two cohorts.

Fig. 1.

Fig. 1.

Patient demographics, comorbidities, neoadjuvant and adjuvant therapies, and operative characteristics including mastectomy weight, acute reconstructive complications, and nipple-areola complex malposition were analyzed and compared between the two cohorts. Major mastectomy flap necrosis was defined as necrosis requiring débridement and minor flap necrosis as that managed with local wound care. Major infection was defined as infection requiring intravenous antibiotics and minor infection as that requiring only oral antibiotics.

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Statistical Analysis

Descriptive statistics and measures of central tendency were used to describe absolute and mean results, respectively; t tests were used to analyze continuous data sets, and Fisher’s exact test was used to compare proportional responses. All statistical analysis was performed using GraphPad Prism (GraphPad Software, Inc., La Jolla, Calif.). A value of p < 0.05 was considered significant.

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A total of 1214 cases of nipple-sparing mastectomy were performed from 2006 to 2017. Of these, nine patients (18 breasts) underwent staged breast reduction before prophylactic nipple-sparing mastectomy (Fig. 2). Average body mass index was 28.1 kg/m2, and no patients had a history of diabetes, smoking at the time of initial consultation, or neoadjuvant therapies. Reductions were performed at an average of 5.0 months before mastectomy (range, 3.0 to 6.8 months), with a mean reduction specimen weight of 383.4 g per breast (Table 1). There was one hematoma (5.6 percent) and no other reconstructive complications after reduction and before mastectomy.

Table 1. - Operative Characteristics of Staged Breast Reduction
Characteristic Value (%)
Skin excision pattern
 Wise 16 (88.9)
 Vertical 2 (11.1)
 Medial 8 (44.4)
 Superomedial 10 (55.6)
Specimen weight, g
 Mean 383.4
 Range 82–1240
Length between BR and NSM, mo
 Mean 5.0
 Range 3.0–6.8
R, breast reduction; NSM, nipple-sparing mastectomy.

Fig. 2.

Fig. 2.

At the time of mastectomy, inframammary fold incisions within prior Wise-patterns scars were most commonly used for access (77.8 percent) (Table 2). The average combined mastectomy weight (sum of mastectomy weight and breast reduction specimen weight) was 992.6 g, and the average isolated mastectomy specimen weight was 607.1 g. The majority of patients underwent immediate implant placement (55.6 percent), followed by two-stage tissue expander reconstruction (33.3 percent) and free autologous tissue transfer (11.1 percent).

Table 2. - Comparison of Patient Demographics and Intraoperative Characteristics between Staged Breast Reduction before Nipple-Sparing Mastectomy and Matched Cases*
Characteristic NSM with Staged BR (%) Nonstaged NSM (Matched Cohort) (%) p
No. 18 36
Age, yr† 43.5 ± 7.6 45.6 ± 11.2 0.4723
BMI, kg/m2 28.1 ± 5.7 25.8 0.1123
Diabetes mellitus† 0 0
Active tobacco use†‡ 0 0
Previous radiation therapy‡ 0 0
Previous chemotherapy† 0 1 (3.2) >0.9999
Postoperative radiation therapy 0 0
Postoperative chemotherapy† 0 1 (3.2) >0.9999
Mastectomy indication‡
 Therapeutic 0 0
 Prophylactic 18 (100) 36 (100)
Mastectomy incision‡ 0.1241
 IMF 14 (77.8) 32 (88.9)
 Vertical 2 (11.1) 4 (11.1)
 Wise pattern§ 2 (11.1) 0
Reconstructive technique‡
 Tissue expander 6 (33.3) 12 (33.3)
 Immediate implant 10 (55.6) 20 (55.6)
 DIEP 2 (11.1) 4 (11.1)
ADM 0.7012
 Yes 14 (87.5) 26 (81.3)
 No 2 (12.5) 6 (18.7)
Implant size, cc 564.3 ± 165.3 481.7 ± 145.9 0.0748
Mastectomy weight, g‡
  Mean ± SD‖ 992.6 ± 472.2 640 ± 222.1 0.0004¶
  Range‖ 544–2183 280–1324
  Mean 607.1 ± 218 640 ± 222.1 0.6311
  Range 208–956 280–1324
Follow-up length, mo† 31.3 ± 19.8 50.2 ± 3.8 0.0015¶
SM, nipple-sparing mastectomy; BR, breast reduction; BMI, body mass index; DIEP, deep inferior epigastric artery perforator flap; IMF, inframammary fold; ADM, acellular dermal matrix.
Continuous variables reported as mean ± SD.
†Patient characteristics analyzed per person (staged cohort,
n = 9; nonstaged cohort, n = 31).
Indicates matching criteria.
One case of Wise-pattern immediate implant staged reconstruction was not able to be matched by incision type. The nearest similar mastectomy weights were used to match the case to nonstaged immediate implant reconstructions with IMF incisions and the same remaining matching criteria.
In the staged breast reduction cohort, combined mastectomy weight is a sum of the breast reduction weight and the mastectomy specimen weight, and isolated mastectomy weight represents only mastectomy specimen weight.
Statistically significant.

Thirty-six matching nonstaged cases were identified. All matched cases were identical for categorical matching variables, with the exception of one case of Wise-pattern immediate implant staged reconstruction, which could not be matched by incision type. This case was matched by the nearest similar mastectomy weights to nonstaged immediate implant reconstructions with inframammary fold incisions and the same remaining matching criteria. Combined mastectomy weight was significantly higher in the staged group (992.6 g versus 640.0 g; p = 0.0004), whereas there was no significant difference in isolated mastectomy weight between the two cohorts (607.1 g versus 640.0 g; p = 0.6311). There were also no significant differences in age, body mass index, comorbidities, or neoadjuvant therapies.

The staged group had one case of nearly total full-thickness necrosis of the nipple-areola complex (5.6 percent) in a combined weight 995-g (isolated 720-g) mastectomy with immediate tissue-expander placement (350 cc intraoperative fill) and staged Wise-pattern, medial pedicle reduction 6.6 months before mastectomy (Table 3). This case of nipple-areola complex necrosis required office débridement and delayed nipple reconstruction. Compared with the staged group, the nonstaged group had a significantly higher rate of major mastectomy flap necrosis (22.2 percent versus 0 percent; p = 0.0415). Minor mastectomy flap necrosis, partial nipple-areola complex necrosis, and minor infections also trended higher in the nonstaged cohort but were not significantly different from staged cases. There were no significant differences in the specific oncologic or plastic surgeon involved in cases with ischemic complications. Reconstructive failures in the nonstaged group were secondary to implant exposure after mastectomy flap necrosis in one case and mastectomy flap necrosis combined with major infection in two cases.

Table 3. - Comparison of Reconstructive Outcomes between Staged Breast Reduction before Nipple-Sparing Mastectomy and Matched Cases
NSM with Staged BR (%) Nonstaged NSM (Matched Cohort) (%) p
No. 18 36
Reconstructive complications
 Minor MF necrosis 2 (11.1) 6 (16.7) 0.7043
 Major MF necrosis 0 8 (22.2) 0.0415*
 Partial NAC necrosis 2 (11.1) 5 (13.9) >0.9999
 Full NAC necrosis 1 (5.6) 2 (5.6) >0.9999
 Minor infection 0 4 (11.1) 0.2888
 Major infection 1 (5.6) 2 (5.6) 0.9999
 Seroma 2 (11.1) 1 (2.8) 0.2550
 Hematoma 0 0
 Reconstructive failure 0 3 (8.3) 0.5428
NAC malposition correction 2 (11.1) 2 (5.6) 0.5963
SM, Nipple-sparing mastectomy; BR, breast reduction; MF, mastectomy flap; NAC, nipple-areola complex.
Statistically significant.

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Severe macromastia and breast ptosis are often considered relative contraindications for nipple-sparing mastectomy given the potential for increased ischemic complications and difficulty achieving satisfactory aesthetic results because of an excessively large and ptotic skin envelope.14,15 In prior series, we have found mastectomy weight to be an independent positive predictor of reconstructive complications, with a 2.6 times increased risk in weights between 400 and 800 g, and 5.1 times increased risk in weights greater than or equal to 800 g.9 This is likely attributable to a greater surface area that requires perfusion based on the same subcutaneous perforators and subdermal plexus,16–18 and greater distance from source vessels to the skin edges with increasing breast size. Furthermore, severely macromastic breasts can make the mastectomy significantly more challenging in terms of visualization and access, usually resulting in greater traction on mastectomy flaps, further compromising perfusion.

Staged reduction emerged as a potential solution to these issues11 for extreme cases in patients with solely morphologic “disindications” for nipple-sparing mastectomy. Nipple-sparing mastectomy has been demonstrated to be safe in patients with a history of breast reduction19 and, furthermore, has theoretical benefits for perfusion. Skin reduction decreases the surface area needed to be perfused and the length of mastectomy flaps and also provides a vascular delay.

In this study, the rate of major ischemic complications in patients that underwent staged reduction was 5.6 percent. This compares well to outcomes from prior studies. Spear et al. reported a partial nipple-areola complex necrosis rate of 15.7 percent and major skin flap necrosis rate requiring operating room débridement of 15.7 percent in 19 breasts that underwent planned staged mastopexy/reduction.11 More recent smaller series with staged inferior pedicle, Wise-pattern reductions have demonstrated lower complication rates.20 In a series of 22 patients undergoing direct-to-implant reconstruction after staged, Wise-pattern breast reduction, Gunnarsson et al. reported no cases of major ischemic complications.13 Average reduction weights were 319 and 305 g per side, similar to our study (383.4 g), although overall breast size is difficult to extrapolate, as mastectomy weights were not provided.

The rate of major mastectomy flap necrosis in the nonstaged group was high though appropriate for this “high-risk” subset of patients. We have previously found major mastectomy flap necrosis rates of 14.2 percent and 42.1 percent in intermediate (400 to 799 g) and large (≥800 g) breasts, respectively, which compares well with the rate of 22 percent in the nonstaged group that had a mean mastectomy weight of 640 g.

Ischemic complications, however, are influenced by multiple intrinsic and extrinsic factors. For this reason, we believe it is pertinent to control for the most well-known factors when attempting to determine the efficacy of staging in reducing complications. Matching allowed for comparison between cases with identical categorical risk factors. One staged case was not able to be matched by incision pattern, as there were no nonstaged immediate implant Wise-pattern cases that were identified. This case was matched by the remaining identical categorical variables and the closest mastectomy weights to a case using an inframammary fold incision. Inframammary fold incision patterns have been found to have a lower risk of ischemic complications in prior studies6 and in our experience, and therefore should not have biased the higher mastectomy flap necrosis rate in the nonstaged group. Importantly, other variables such as age and body mass index that have been described as risk factors in other studies,6,21 but have not been found to be consistent risk predictors at our institution (and therefore were not included as matching criteria), were similar between the two cohorts.

Despite isolated mastectomy weights being similar between both cohorts and a greater combined mastectomy weight in the staged group, rates of major mastectomy flap necrosis were significantly lower in the staged group. This observation suggests a potential benefit from staging beyond just reducing mastectomy weight. Additional factors may include vascular delay and an easier mastectomy dissection with less tension placed on flaps. In this series, the most common incision patterns for staged reductions were Wise-pattern (88.9 percent), allowing for a greater area of skin excision and reduction of the overall soft-tissue envelope. Staged reduction also allows for molding of a more favorable breast mound and setting the desired shape and nipple position before mastectomy. This “preshaping,” as described by Gunnarsson et al.,13 further decreases the amount of skin and nipple-areola complex manipulation at the time of mastectomy that may jeopardize already tenuous perfusion. We believe that optimization of the skin envelope is a critical factor that should be considered along with the primary issue of breast size. Although the lowest combined mastectomy weight in the staged group of 544 g is not considered an overly large breast, the patient’s grade III ptosis and contralateral 638-g breast indicated a preemptive reduction to improve nipple position, control the skin envelope, and decrease the need for retraction on skin flaps at the time of mastectomy.

Average follow-up length was longer in the nonstaged cohort by approximately 18.9 months, as staged reductions have been more recently adopted. This discrepancy may be considered as a confounder contributing to the higher mastectomy flap necrosis rate in the nonstaged cohort. However, the earliest staged case was performed in 2013, with 88.9 percent of nonstaged cases performed after this time as well. Differences in mastectomy and reconstruction techniques must always be considered as a potential source of bias, though these techniques, and the oncologic and plastic surgeons performing these cases, have remained consistent during the studied period.

Mastectomy flap quality is a critical variable in the evaluation of ischemic complications. Unfortunately, objective quantification of mastectomy flap thickness could not be performed in this series, as there was a limited number of patients with postoperative magnetic resonance imaging scans, particularly in prophylactic nipple-sparing mastectomy cases. Mastectomy flap quality, however, likely plays an important role in the increased risk of ischemic complications in nonstaged nipple-sparing mastectomies with large, ptotic breasts. Aside from inherent differences in vascularity of large mastectomy flaps, severe macromastia may result in deviations from the plane of dissection and damage to the subdermal plexus and increased retraction on skin flaps during mastectomy. As in nonstaged cases, precise dissection at the level of the breast capsule with preservation of nonparenchymal subcutaneous tissues is critical. Respecting the superficial perfusion of the nipple-areola complex from internal mammary artery perforators traveling in this tissue is paramount for staged procedures given the partial disruption of the random-pattern blood supply by scarring. Vascular delay can provide more robust perfusion in the remaining subcutaneous tissue, but this tenuous blood supply must be carefully protected during mastectomy, as collateral perfusion is limited. Along these same lines, the use of a superomedial or medial pedicle during breast reduction is highly recommended to preserve the second and third interspace internal mammary artery perforators, which are otherwise sacrificed with use of an inferior pedicle.

Aesthetic considerations of staging should also be taken into account. Two cases in a single-stage patient required correction of nipple malposition. The same patient had minor ischemic complications, which we have previously found to be a risk factor for secondary nipple-areola complex repositioning.22 Overall, we have found that premastectomy shaping of the breast allows for a more fluid reconstruction, as breast size and nipple position are appropriately set at the time of reduction, similar to prior reports.13

The primary drawback of staging is the need for an additional operation. However, premastectomy reduction can decrease the likelihood of revision for complications, such as mastectomy flap necrosis, or for asymmetries that are more common after nipple-sparing mastectomy in significantly large and ptotic breasts. In addition, these procedures are currently limited to prophylactic cases in our experience. Spear et al., however, described planned staged mastopexies in five patients with breast cancer.11 Timing between stages plays an important role in consideration of therapeutic cases. In our practice, nipple-sparing mastectomy is generally planned for 3 months after reduction, with an average period of 5 months between stages in this series. Prior studies, however, have reported a minimum of 4 weeks between stages.11 Shorter times between stages requires further investigation and may lend smaller node-negative tumors or cases of in situ carcinoma amenable to staging.

Importantly, certain patients remain poor candidates for prophylactic nipple-sparing mastectomy with or without staged techniques. Aside from oncologic considerations, patients with a combination of severe macromastia and ptosis, along with significant systemic comorbidities, active tobacco use, or radiation therapy, are currently not offered nipple-sparing mastectomy staging. These considerations must be discussed thoroughly with patients preoperatively to arrive at a mutual decision that represents the best individualized choice.

The large and ptotic breast has always been a challenge for oncologic and plastic surgeons. Aside from staged reduction, many additional techniques for handling the excess skin envelope and maximizing skin envelope perfusion have been described. Other staged procedures for patients at high risk for ischemic complications, including those with severe ptosis and macromastia, include nipple-areola complex delay with partial devascularization of the nipple-areola complex,23–25 or a short period of delay after mastectomy and before reconstruction.26,27 Although nipple-areola complex delay can increase perfusion to the nipple-areola complex and subsequently decrease nipple-areola complex necrosis rates, it does not address perfusion to the mastectomy flaps or nipple-areola complex position. Along the same lines, immediate-delayed reconstruction does not address mastectomy flap length and increased surface area. Although these techniques improve nipple-areola complex perfusion, they do not address the problem itself: breast size and degree of ptosis remain the same at the time of mastectomy.

Single-stage skin reduction techniques are well-described for skin-sparing mastectomy28–31 and have also been used for nipple-sparing mastectomy.32 These procedures most commonly use different mastopexy techniques with varying amounts of skin resection through Wise-pattern skin incisions.28,32 Single-stage Wise-pattern skin reduction, however, can have an increased rate of ischemic complications, particularly at T-point incisions. Rochlin and Nguyen report an 18.2 percent partial flap necrosis rate and a 12.5 percent partial nipple necrosis rate.24 Although we routinely use Wise-pattern mastectomy incisions for moderate- to large-size breasts with ptosis, we have found that in patients with more severe macromastia, single-stage Wise-pattern incisions can be treacherous. Decreased subdermal perfusion at mastectomy flap corners, combined with traction on inherently thinner flaps at skin edges, results in T-point necrosis and dehiscence. Other techniques such as doughnut33 and button-hole mastopexy34 have shown promising outcomes. Although single-stage skin reduction nipple-sparing mastectomy can be an excellent choice in certain patients, stringent patient selection and precise surgical technique to preserve healthy mastectomy flaps are critical factors in minimizing complications with these techniques.

Limitations of the study include its retrospective nature. As data were not collected prospectively, certain variables that may have been useful in analysis could not be used, such as objective intraoperative indicators of mastectomy flap quality, nipple-areola complex malposition that did not require correction, and objective comparison of aesthetic outcomes. Comparison of aesthetic results is an important aspect of the evaluation of overall outcomes with staged reduction and is the subject of future studies. In addition, the staged group was limited in sample size, as young patients with severe macromastia and mutations that have a high risk for breast cancer are a small proportion of our practice. Further analysis in larger populations may elucidate additional differences between the two cohorts not captured because of a smaller sample size. In addition, strict adherence to the matching algorithm and multiple categorical matching criteria resulted in a low nonstaged mastectomy weight (280 g). Although this outlier falls outside the range of a “large” breast, it was critical to follow the fixed selection procedure to avoid selection bias. Mean breast size (640 g) in the nonstaged group was large and above the threshold for increased risk of complications determined in prior studies.9 Along the same lines, mean combined mastectomy weight was significantly higher in the staged group despite matching because of the inclusion of multiple matching criteria and the severity of macromastia in staged patients. However, isolated mastectomy weights were comparable between the two cohorts. Furthermore, an even higher mastectomy weight in the nonstaged group should only further exaggerate the risk of mastectomy flap necrosis9 and therefore the theoretical benefit of staging. Finally, patient-reported results are needed in the evaluation of outcomes and are the subject of future studies.

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As breast reconstruction after nipple-sparing mastectomy continues to evolve, techniques must be refined to further optimize outcomes and minimize complications. Staged reduction appears to decrease the risk of ischemic complications compared with nonstaged cases and may therefore serve as a useful modification of traditional immediate reconstruction techniques. Larger, prospective analyses will help further definitively determine the ability of staged reduction to expand nipple-sparing techniques to the appropriate patients with severe macromastia undergoing mastectomy.

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The authors would like to thank David Gothard, M.S., at Biostats, Inc., for assistance with study design and statistical analysis.

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