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A Two-Step Approach to Prophylactic Nipple-Sparing Mastectomy in Patients with Ptosis or Macromastia and Genetic Predispositions to Breast Cancer
Abigail Meyers, Stephanie Wythe, Stephanie Valente, Graham Schwarz, Steven Bernard
Cleveland Clinic Department of Plastic Surgery (Abigail Meyers, Stephanie Wythe, Graham Schwarz, Ste
2023-01-31
Presenter: Abigail Meyers
Affidavit:
Agree. Original work by the medical student, plastic surgery resident, and combined plastic and breast surgery teams.
Director Name: Steven Bernard
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)
Purpose
Nipple sparing mastectomy (NSM) is an oncologically safe option for patients at high risk for breast cancer. However, large and ptotic breasts present reconstructive challenges, particularly due to nipple-areolar complex (NAC) placement and complications. We present outcomes of patients treated with two-step prophylactic NSM.
Methods
A retrospective review was conducted on patients who underwent reduction mammaplasty or mastopexy followed by completion of prophylactic NSM with immediate reconstruction. Breast measurements, ptosis grade, surgical techniques, and postoperative outcomes were collected. Primary outcome was achievement of stable healing with viable NAC. Secondary outcomes included complications and management.
Results
Fourteen patients (median age 38 [34-40] years, BMI 31 [29-34]) underwent two-step NSM. Median ptosis was grade 3 [3-3], average SN-N 29±3cm (25-35) right and 29±3cm (24-33) left, and N-IMF 11±2cm (9-16) right and 11±2cm (9-16) left. Eleven patients underwent breast reduction, three mastopexy. NSMs were performed a median of 4 [3-6] months later: 622±235g (340-1040) right and 641±228g (340-1041) left. Immediate reconstructions were 43% direct pre-pectoral implant (608±128cc), 36% DIEP, 21% expander.
Median follow-up was 18 [12-25] months. Complications requiring reoperation included seroma (x2), hematoma (x1), mastectomy flap necrosis (x1), NAC malposition (x1). Minor complications included infection treated with oral antibiotics (x5) and wound dehiscence (x4). All patients ultimately achieved stable healing with viable NACs bilaterally within the study period.
Conclusion
Our two-step approach for large or ptotic breasts has produced reliable reconstructions and gives this patient population the option to choose NSM for oncologic prophylaxis when they would not be candidates otherwise.
