There seemed to be some tendency for patients with NAC necrosis to have higher degree of ptosis in evaluating the association between necrotic complications and degree of ptosis. We additionally focused on individual degree of ptosis (Table 5). On statistical analysis, no statistically significant differences between groups could demonstrate association between degree of ptosis and NAC necrosis.
Duration of operation, type of surgical incision, and type of reconstruction were not statistically significant (Table 7). Similarly, we could not find the significant correlation between the total expander or prosthesis volume and the risk of necrotic complications.
To evaluate more efficiently the possible association between skin incision types and necrosis, we combined superior circumareolar and periareolar skin incisions for comparing with other skin incisions (Table 8). We found 25% NAC necrosis with superior circumareolar and periareolar incisions as compared with 13% necrosis with other incisions. There was no statistically significant difference between the 2 groups of skin incisions.
The objective of our study was to evaluate the relationship between the morphology of the breast and the risk of NAC and skin necrosis. Our study showed a 4% rate of NAC removal consistent with the results of the literature (range, 0.0–29%).4,9,13,17,19,27 The volume of breast removed was the only factor significantly associated with NAC necrosis. We observed a trend of higher risk of necrosis in ptotic breast, with larger volume of breast removed and larger volume of prosthesis inserted for the reconstruction, which were not significant (Tables 5 and 6). Rusby and Gui28 described a higher risk of necrosis in patients with large or ptotic breast, but there is no study showing an association between degree of ptosis and the risk of NAC necrosis in the NSM procedure. In our study, patients with ptosis grade 0 had only 9% of NAC necrosis compared with higher percentages of NAC necrosis in higher grade ptosis (11–19%). This finding should be investigated further in larger studies. Because of the risk of local recurrence in the breast parenchyma preserved beneath the NAC for the vascular supply, we performed the NSM with the ELIOT technique. The single application of 16 Gy should be sufficient to sterilize more than 90% of the residual cancer cells. The risk of radiodystrophy is low with ELIOT. A mild pigmentation was reported in 20% of the patients at 1-year follow-up, and no local recurrence was observed on NAC area.8 Type of reconstruction was not significantly associated with NAC necrosis in our study. This was different from other studies showing a significant impact of reconstructive techniques on necrotic complications.13,17,19 The lack of association in our study was probably due to selection bias. The choice of reconstructive technique is related to the quality of the blood supply of the skin at the end of mastectomy. We usually preferred to place an expander only moderately inflated but may choose an autologous flap reconstruction in case of poor blood supply of the skin envelope. Skin incision types are not related to necrotic complications in our study. Several studies have shown that incision types are an important risk factor of NAC necrosis.13,17,29,30 Regolo et al31 reported of 60% NAC loss with the periareolar incision. As we know, the periareolar incision provides the best cosmetic outcomes. This incision limits the view of operative field and may compromise blood supply to the NAC.32,33 Lateral or inframammary incisions give a better view in the operative field and does not compromise blood supply to the NAC.34 Other authors also favor the use of radial or lateral incisions.13,15 In contrast, Paepke et al35 reported only a 1% NAC loss with periareolar incision. Algaithy et al19 recommended maintaining a 5 mm thickness of the areola and periareolar area to prevent from flap necrosis. In our study, the superior circumareolar and periareolar incisions were associated with a NAC necrosis rate of 25% as compared with a rate of 13% with other incisions, but this difference was not statistically significant. It seems likely that the variation in the NAC necrosis rates may relate to the individual surgeon’s technique. Smoking history is not related to NAC necrosis in our study, but the literatures have shown that smoking status is an important risk factor for NAC necrosis.17,19 However, the number of smokers in our study was too small to show a significant association. Diabetes mellitus, hypertension, and dyslipidemia were nonsignificant risk factors for NAC necrosis. Although there was no relation between BMI and NAC necrosis in our study, Davies et al29 reported higher risk of skin necrosis in women with BMI greater than 25 kg/m2 and Platt et al36 also showed higher rate of wound complication for higher BMI women.30 The nipple sternal notch distance did not influence the risk of skin necrosis in our study as mentioned in different studies.37–39 There is no study showing the correlation between volume of breast removed and NAC necrosis after performing NSM. The study by Nahabedian et al40 reported the risk of flap-related complication due to inadequate vascular perfusion in patient with breast volume larger than 1000 cm3. Our study showed a positive relationship between larger breast volume removed and higher NAC necrosis rate which was most marked for the cutoff of 750 cm3. This finding may be related to the method of the glandular specimen measurement. The influence of the individual surgeon’s technique on NAC necrosis should be investigated further in larger studies.
Despite a relatively high necrotic complication rate (17.7%) after therapeutic NSM, NSM remains an option for appropriately selected patients. Our study underlined the risk of skin and NAC necrosis in patients with larger breasts and suggests careful consideration of the choice of breast reconstruction in such cases, such as the use of tissue expanders with slow expansion or autologous musculocutaneous flap.
We wish to acknowledge Asst. Prof. Dr. Gloria Vidheecharoen and Assoc. Prof. Panuwat Lertsithichai for English revision of the text.
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