Abstract
Background
Nipple-sparing mastectomy in medium-large, ptotic breasts presents challenges because of redundant skin and risks to the nipple–areola complex (NAC). Advances in skin-reducing techniques and immediate prepectoral reconstruction aim to improve both oncological safety and aesthetic outcomes.
Objectives
The authors of this study present a novel surgical approach designed to enhance NAC vascularization by performing a nipple-sparing skin-reducing mastectomy exclusively through the lower lateral triangle of a Wise-pattern incision with immediate prepectoral polyurethane-coated breast implant (Microthane, POLYTECH, Dieburg, Germany) reconstruction. This approach seeks to minimize implant exposure risks by limiting the scar laterally, thus optimizing breast contour and patient satisfaction.
Methods
A prospective analysis of 10 patients undergoing monolateral procedures was conducted between April and August 2023. Inclusion criteria included Grade 2 ptosis with an expected nipple repositioning of ≤8 cm. The technique preserved vascular connections through precise de-epithelialization and assessed intraoperative flap perfusion. Implant selection ensured symmetry. Postoperative outcomes were evaluated using the BREAST-Q questionnaire and routine follow-ups (18 months). Associations between BREAST-Q scores and patient characteristics were analyzed through Pearson correlation and analysis of variance.
Results
Mean patient age was 52 years, BMI 24 kg/m2, and implant volume 328 cc. Complication rates were low, with no cases of capsular contracture or implant displacement. BREAST-Q scores demonstrated high satisfaction, and a significant positive correlation was found between BMI and physical well-being (P = .03).
Conclusions
This single-stage technique for immediate prepectoral breast reconstruction in ptotic breasts may be safe and provide good aesthetic and functional outcomes. Further studies with extended follow-up and greater numbers are warranted.
Level of Evidence: 4 (Therapeutic)
Implant-based breast reconstruction after nipple-sparing mastectomy (NSM) is nowadays considered an oncologically safe and reliable option in many breast cancer patients; it is associated with good cosmetic results and better quality of life.1 However, large and ptotic breasts present significant difficulties in surgical management, as the skin envelope may be redundant, and the removal of the supportive breast tissue underneath may damage the nipple–areola complex (NAC). Thus, these patients with notably large and ptotic breast often experience complications such as nipple necrosis or dislocation and persistent edema of the skin flaps, with unsatisfactory outcomes when NSM is performed. Nava et al described in 2006 a new technique called “skin-reducing mastectomy” that consists of a Wise-pattern mammoplasty incision with a de-epithelialized dermal sling and direct submuscular implant insertion.2 This procedure allows reconstruction of medium-large and ptotic breasts without the need for myocutaneous pedicled or free flaps. The Wise-pattern incision has been proposed in patients with medium-large and ptotic breasts because it allows the preservation of the skin around the NAC, lifts and cones the breast into a less ptotic shape, and removes skin redundancy.3 Moreover, prepectoral reconstruction with or without acellular dermal matrix (ADM) is currently considered a common and safe technique, allowing to overcome several complications of subpectoral implants, such as capsular deformity, implant displacement, reduction in strength of pectoral muscles, loss of muscle function, and chronic pain.4 In addition, the current trend is to perform breast reconstruction simultaneously with oncological surgery rather than a 2-stage reconstruction with tissue expanders, avoiding 2 operative steps and several follow-up visits.5-8
In this study, we describe an original technique of nipple-sparing skin-reducing mastectomy through the lower lateral triangle of a Wise pattern with an immediate prepectoral reconstruction polyurethane-coated anatomical implant (Microthane, POLYTECH, Dieburg, Germany) preserving the vascular dermal connections as much as possible. The purpose of the authors of this study is to illustrate our findings with a new surgical procedure of mastectomy combined with simultaneous removal of excess breast skin in individuals presenting medium-large and ptotic breasts, performing an immediate prepectoral implant-based reconstruction, reporting technique reliability, and the satisfaction level of the patients.
METHODS
We conducted a prospective data collection including all the nipple-sparing skin-reducing mastectomies through the lower lateral triangle and prepectoral breast reconstructions performed between April 2023 and August 2023.
Overall, we performed 10 nipple-sparing skin-reducing mastectomies combined with immediate direct-to-implant prepectoral breast reconstructions using anatomical polyurethane-coated implant (mono-lateral procedure). The anatomical implant was positioned directly beneath the skin, without additional coverage. The patients were administered the Breast-Q score to evaluate breast satisfaction, postoperative results, and physical well-being.9 This study was carried out in compliance with the ethical standards in the Declaration of Helsinki. A detailed written informed consent was given to the patients.
Patient Selection
All patients who met the criteria outlined below were eligible for the proposed procedure. The inclusion criteria were patients with Grade 2 breast ptosis (defined as breasts in which the nipple position is located below the inframammary fold). The degree of ptosis was calculated according to Regnault's classification, with an expected rise in NAC position after NSM skin reducing of no more than 8 cm, in which a prepectoral reconstruction can be performed.10 At presurgical evaluation, an adequate breast tissue coverage on the digital mammogram of at least 1 cm, corresponding to a Class 2 or 3 according to Rancati classification, was considered necessary for inclusion in the study.11
Exclusion criteria consisted of patients with Stage IV breast cancer or considered to have a high risk of recurrence, skin and/or nipple involvement, and those presenting comorbidities including uncontrolled glycemia, severe obesity, and chronic immunosuppression. Active tobacco use is not considered a contraindication for our procedure.
Surgical Technique
All surgical procedures were conducted collaboratively by oncological and reconstructive surgeons under general anesthesia. Before starting the operation with the patient in a standing position, preoperative markings were made according to the rules of the Wise pattern: the NAC was repositioned by marking it along the breast meridian at the projected level of the inframammary fold on the breast's anterior surface. The 2 lateral margins of the marking were traced following the Aufricht maneuver, and after that, 2 horizontal lines were drawn at a distance from the lower side of the areola to the new inframammary sulcus between 6 and 8 cm (Figures 1, 2). The incision, where the oncology surgeon performed the mastectomy, was marked from the lower lateral triangle of the Wise pattern (Video 1). So, the oncology surgeon undertook the mastectomy from the lower lateral triangle of the Wise pattern. The dissection was performed with scissors in the superficial plane, whereas electrocautery was utilized to detach the mammary gland from the pectoral muscle. Particular care was taken to preserve tissue vascularity and avoid ischemic injury because of excessive traction. The measurements of the breast base and height were taken to identify the correct prosthesis to reconstruct a breast shape suitable for patient's anatomy (Video 2). Choosing the most suitable anatomical implant for the patient also considers symmetry in terms of shape and volume of the contralateral breast. Any necessary axillary surgery was performed through a different skin incision in the axillary. The preservation of superficial vascularization of the breast was essential to perform prepectoral reconstruction, maintaining the subcutaneous breast layer by an accurate dissection at the superficial breast fascia level. After mastectomy, a residue skin envelope of breast tissue of 1 cm was considered mandatory to perform our breast reconstruction, and the mastectomy flap had to appear well vascularized.11 Perfusion of mastectomy flaps was evaluated intraoperatively through clinical signs including color, temperature, bleeding from flap edges, and capillary refill without the support of indocyanine green, which was not available in our institution at the time of surgery. If the mastectomy flaps appeared too thin or not well vascularized, we proceeded intraoperatively with placement of a submuscular tissue expander. After the evaluations of thickness from the lower lateral incision of the Wise pattern, the sizer previously identified based on the measurements in the preoperative planning was positioned inside the prepectoral pocket, and it was evaluated whether the preoperative skin marking was correct or whether it was necessary to make some changes. After that, the entire portion of skin remaining within the Wise pattern design was de-epithelialized without making further incisions (Figure 3). Then the polyurethane-coated implant previously irrigated with gentamicin and vancomycin was inserted (Video 3). A suction drain was placed in the subcutaneous pocket, and it was kept in place until drainage was <20 to 25 cc per day for 2 consecutive days (Video 4). Closure was then completed at the deep dermal and subcuticular levels. We performed the intradermal suture in the horizontal and vertical portions of the inverted T and single dermal-epidermal stitches at the level of the areola (Figure 4). The perioperative antibiotic was given 30 min before the surgical incision and continued in the following days, following the recommendations of the Italian Society of Plastic Surgery (SICPRE), which advises perioperative prophylaxis for up to 72 h. A postoperative compression bra was applied immediately following surgery.
Figure 1.
A 44-year-old female patient. The preoperative drawing was carried out according to the rules of Wise-pattern marking: the incision, where the oncology surgeon performed the mastectomy, was marked from the lower lateral triangle of Wise pattern.
Figure 2.
A 44-year-old female patient. The oncology surgeon undertook the mastectomy from the lower lateral triangle of the Wise pattern.
Figure 3.
A 44-year-old female patient. The portion of skin remaining within the Wise-pattern design was de-epithelialized without making further incisions.
Figure 4.
A 44-year-old female patient. The polyurethane-coated implant was inserted, and the sutures were performed.
Statistical Analysis
Demographic data (including age and BMI), as well as medical and surgical details (eg, treatments, implant size, and complications), were analyzed using descriptive statistics. Continuous data were presented as mean and range. Categorical data were summarized using counts of patients with corresponding percentages. Breast-Q scores were derived using the QScore program.
The domain-specific scores were analyzed in relation to the patients' demographic, medical, and surgical characteristics through mean values and standard deviations. Pearson's correlation coefficient was utilized to explore potential associations between BreastQ scores and continuous variables. Analysis of variance was conducted to assess differences in Breast-Q scores across groups defined by categorical variables. All tests of hypotheses were conducted at the .05 significance level.
RESULTS
Patients' demographics, medical history, and surgical details were gathered from our prospectively maintained databases (Table 1). Patients had a mean age of 52.0 years (range, 44-63 years) and an average BMI of 24 kg/m2. Mean implant volume was 328 cc (from 265 to 375 cc). Forty percent of women (n = 4) were smokers, 1 patient received neoadjuvant chemotherapy (10%), and 6 patients received adjuvant chemotherapy (60%). Adjuvant radiotherapy was administered in 10% of patients (n = 1).
Table 1.
Patient Data
| Parameters | Values |
|---|---|
| No. of patients | 10 |
| No. of breasts | 10 |
| Average age, years (range) | 52 (44-63) |
| Average BMI, kg/m2 (range) | 24 (20-29) |
| No. of smokers | 40% (4) |
| Indication for surgery | |
| No. of DCIS | 20% (2) |
| No. of IDC | 40% (4) |
| No. of ILC | 40% (4) |
| Lymph node management | |
| No. of SLNB | 80% (8) |
| No. of ALND | 20% (2) |
| Adjuvant radiation therapy (n) | 10% (1) |
| Neoadjuvant chemotherapy (n) | 10% (1) |
| Adjuvant chemotherapy (n) | 60% (6) |
| Average nipple-to-sternum notch distance, cm (range) | 29 (26-32) |
| Mean hospital stay, days (range) | 2 (2-2) |
| Average implant size, cc (range) | 328 (265-375) |
ALND, axillary lymph node dissection; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; SLNB, sentinel lymph node biopsy.
Postoperative complications were recording during clinical evaluations at 7, 15, 30, and 90 days postsurgery and after 6 months (Table 2). Operative complications were ranked according to the Clavien–Dindo classification.12 Complications included mastectomy skin flap necrosis, necrosis of the NAC, surgical site infection, seroma, wound dehiscence, Grades III and IV of capsular contracture according to the Baker scale, hematoma, rippling, implant exposure, as well as displacement issues. After a 6-month follow-up, we did not observe significant complications (maximum follow-up was 18 months, the average patient follow-up time was 10 months). No cases of Grades III and IV capsular contracture occurred. We only observed 1 case of partial NAC necrosis (10%), which healed with conservative treatment, and 1 case (10%) of seromas and hematoma in the same patient, managed with drainage. We observed rippling in 3 patients (30%) after 6 months of follow-up.
Table 2.
Surgical Complications
| Complications | Values |
|---|---|
| Wound dehiscence | 0 |
| NAC necrosis | |
| Partial | 10% (1) |
| Complete | 0 |
| Mastectomy skin flap necrosis | 0 |
| Prosthetic exposure | 0 |
| Surgical site infection | 0 |
| Seroma | 10% (1) |
| Hematoma | 10% (1) |
| Rippling | 30% (3) |
| Capsular contracture | 0 |
| Displacement issues | 0 |
Breast-Q with 9 domains was reported: physical, psychosocial, and sexual well-being; breast satisfaction; outcome satisfaction; satisfaction about information provided; satisfaction with the surgeon; and satisfaction with the medical and administrative staff. Breast-Q scores vary from 0 to 100. Higher scores reflect greater satisfaction or improved health-related quality of life (Table 3). A statistical evaluation was conducted using patient characteristics and the related data on Breast-Q. Results obtained are illustrated in Tables 4 and 5. The results of the well-being domains (physical, psychological, and sexual) and the quality of life represent the average of these 3 parameters (Table 4). Greater physical well-being at Breast-Q was statistically significantly correlated with a higher BMI as well as a higher volume of the implant. Statistical analysis was also performed between the characteristics of the patients and the 3 domains of satisfaction (with the breast, outcome, and care provided), where care satisfaction was obtained as the average of satisfaction with the doctor, with staff and with information (Table 5). Greater satisfaction with the result obtained was significantly correlated with a higher BMI recorded at surgery. However, all patients reported satisfaction with the final results in all Breast-Q domains (Figures 5-8).
Table 3.
Breast-Q
| Domains | Score (range, 0-100) |
|---|---|
| Average physical well-being | 82 (70-100) |
| Average psychosocial well-being | 83 (70-90) |
| Average sexual well-being | 75.5 (70-85) |
| Average satisfaction with breast | 90 (80-100) |
| Average satisfaction with outcome | 91 (80-100) |
| Average satisfaction with information | 96 (90-100) |
| Average satisfaction with surgeon | 100 (100-100) |
| Average satisfaction with the medical team | 98 (90-100) |
| Average satisfaction with admin staff | 99 (90-100) |
Table 4.
Association of Breast-Q Well-being Domains With Patient's Data (Correlation and Analysis of Variance Results)
| Physical | Psychological | Sexual | QoL | |
|---|---|---|---|---|
| Smoke | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 6) | 81.67 (9.83) | 83.33 (8.16) | 76.67 (5.16) | 80.56 (6.47) |
| Yes (n = 4) | 82.5 (12.58) | 82.5 (5) | 78.75 (6.29) | 81.25 (4.17) |
| P-value | .909 | .8611 | .5811 | .8551 |
| Cancer | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| DCIS (n = 2) | 75 (7.07) | 75 (7.07) | 77.5 (10.61) | 75.84 (8.25) |
| IDC (n = 4) | 77.5 (9.57) | 85 (5.77) | 80 (0) | 80.84 (5) |
| ILC (n = 4) | 90 (8.16) | 85 (5.77) | 75 (5.77) | 83.34 (3.85) |
| P-value | .121 | .177 | .4773 | .3081 |
| Lymph node | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| SLNB (n = 8) | 80 (9.26) | 82.5 (7.07) | 76.88 (5.94) | 79.79 (5.52) |
| ALND (n = 2) | 90 (14.14) | 85 (7.07) | 80 (0) | 85 (2.36) |
| P-value | .2415 | .6666 | .497 | .2438 |
| Radiotherapy | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 9) | 82.22 (10.93) | 82.22 (6.67) | 77.22 (5.65) | 80.56 (5.65) |
| Yes (n = 1) | 80 (NA) | 90 (NA) | 80 (NA) | 83.33 (NA) |
| P-value | .8518 | .3005 | .6535 | .6542 |
| Neochemotherapy | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 9) | 82.22 (10.93) | 82.22 (6.67) | 77.22 (5.65) | 80.56 (5.65) |
| Yes (n = 1) | 80 (NA) | 90 (NA) | 80 (NA) | 83.33 (NA) |
| P-value | .8518 | .3005 | .6535 | .6542 |
| Chemotherapy | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 4) | 85 (10) | 85 (5.77) | 77.5 (5) | 82.5 (5) |
| Yes (n = 6) | 80 (10.95) | 81.67 (7.53) | 77.5 (6.12) | 79.72 (5.81) |
| P-value | .486 | .477 | 1 | .4581 |
| Seroma | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 9) | 82.22 (10.93) | 82.22 (6.67) | 77.22 (5.65) | 80.56 (5.65) |
| Yes (n = 1) | 80 (NA) | 90 (NA) | 80 (NA) | 83.33 (NA) |
| P-value | .8518 | .3005 | .6535 | .6542 |
| Hematoma | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 9) | 82.22 (10.93) | 82.22 (6.67) | 77.22 (5.65) | 80.56 (5.65) |
| Yes (n = 1) | 80 (NA) | 90 (NA) | 80 (NA) | 83.33 (NA) |
| P-value | .8518 | .3005 | .6535 | .6542 |
| Rippling | 82 (10.33) | 83 (6.75) | 77.5 (5.4) | 80.84 (5.4) |
| No (n = 7) | 84.29 (11.34) | 82.86 (7.56) | 75.71 (5.35) | 80.95 (6.3) |
| Yes (n = 3) | 76.67 (5.77) | 83.33 (5.77) | 81.67 (2.89) | 80.56 (3.47) |
| P-value | .3122 | .9255 | .1131 | .9223 |
| Age | ||||
| Correlation | 0.0781 | 0.2065 | 0.1359 | 0.1812 |
| P-value | .8302 | .5671 | .7081 | .6163 |
| BMI | ||||
| Correlation | 0.6664 | 0.3399 | 0.2832 | 0.6608 |
| P-value | .0354 | .3366 | .4278 | .0375 |
| Nipple distance | ||||
| Correlation | −0.0589 | −0.6312 | 0.0563 | −0.2816 |
| P-value | .8715 | .0503 | .8771 | .4306 |
| Volume implant | ||||
| Correlation | 0.6478 | 0.4978 | 0.5502 | 0.8037 |
| P–value | .0428 | .1431 | .0994 | .0051 |
Significant P-values are highlighted in red.
ALND, axillary lymph node dissection; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; NA, not applicable; QoL, quality of life; SLNB, sentinel lymph node biopsy.
Table 5.
Association of Breast-Q Satisfaction Domains With Patient's Data (Correlation and Analysis of Variance Results)
| Satisfaction with breast | Satisfaction with outcome | Satisfaction with care | |
|---|---|---|---|
| Smoke | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 6) | 90 (8.94) | 90 (6.32) | 98.33 (3.03) |
| Yes (n = 4) | 90 (8.16) | 92.5 (9.57) | 98.13 (2.39) |
| P-value | 1 | .6288 | .9113 |
| Cancer | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| DCIS (n = 2) | 90 (0) | 95 (7.07) | 98.75 (1.77) |
| IDC (n = 4) | 82.5 (5) | 85 (5.77) | 99.38 (1.25) |
| ILC (n = 4) | 97.5 (5) | 95 (5.77) | 96.88 (3.75) |
| P-value | .0078 | .0949 | .4423 |
| Lymph node | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| SLNB (n = 8) | 90 (7.56) | 91.25 (6.41) | 97.81 (2.81) |
| ALND (n = 2) | 90 (14.14) | 90 (14.14) | 100 (0) |
| P value | 1 | .8445 | .324 |
| Radiotherapy | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 9) | 91.11 (7.82) | 92.22 (6.67) | 98.06 (2.73) |
| Yes (n = 1) | 80 (NA) | 80 (NA) | 100 (NA) |
| P-value | .2145 | .1202 | .5186 |
| Neochemotherapy | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 9) | 91.11 (7.82) | 92.22 (6.67) | 98.06 (2.73) |
| Yes (n = 1) | 80 (NA) | 80 (NA) | 100 (NA) |
| P-value | .2145 | .1202 | .5186 |
| Chemotherapy | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 4) | 92.5 (9.57) | 90 (8.16) | 98.13 (3.75) |
| Yes (n = 6) | 88.33 (7.53) | 91.67 (7.53) | 98.33 (2.04) |
| P-value | .4619 | .7483 | .9113 |
| Seroma | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 9) | 91.11 (7.82) | 92.22 (6.67) | 98.06 (2.73) |
| Yes (n = 1) | 80 (NA) | 80 (NA) | 100 (NA) |
| P-value | .2145 | .1202 | .5186 |
| Hematoma | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 9) | 91.11 (7.82) | 92.22 (6.67) | 98.06 (2.73) |
| Yes (n = 1) | 80 (NA) | 80 (NA) | 100 (NA) |
| P-value | .2145 | .1202 | .5186 |
| Rippling | 90 (8.16) | 91 (7.38) | 98.25 (2.65) |
| No (n = 7) | 92.86 (7.56) | 92.86 (4.88) | 97.86 (3.04) |
| Yes (n = 3) | 83.33 (5.77) | 86.67 (11.55) | 99.17 (1.44) |
| P-value | .0899 | .2453 | .5063 |
| Age | |||
| Correlation | 0.2187 | 0.5324 | −0.0592 |
| P-value | .5439 | .1131 | .871 |
| BMI | |||
| Correlation | 0.6556 | 0.6737 | −0.2527 |
| P-value | .0396 | .0327 | .4813 |
| Nipple distance | |||
| Correlation | 0.2236 | 0.5774 | 0.1149 |
| P-value | .5346 | .0805 | .752 |
| Volume implant | |||
| Correlation | 0.2696 | 0.1849 | 0.3033 |
| P-value | .4514 | .609 | .3942 |
Significant P-values are highlighted in red.
ALND, axillary lymph node dissection; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; NA, not applicable; SLNB, sentinel lymph node biopsy.
Figure 5.
A 44-year-old female patient. Preoperative picture. Breast cancer was on the left side.
Figure 8.
One-year follow-up for the 51-year-old female patient shown in Figure 7: the patient reported high satisfaction with the final results in all Breast-Q domains. We performed a nipple-sparing skin-reducing mastectomy of the left side through the lower lateral triangle of a Wise pattern with an immediate prepectoral reconstruction polyurethane-coated anatomical implant and breast reduction of the right side.
Figure 6.
A 3-month follow-up for the 44-year-old female patient shown in Figure 5: the patient reported high satisfaction with the final results in all Breast-Q domains. We performed a nipple-sparing skin-reducing mastectomy of the left side through the lower lateral triangle of a Wise pattern with an immediate prepectoral reconstruction polyurethane-coated anatomical implant and mastopexy of the right side.
Figure 7.
A 51-year-old female patient, preoperative picture. Breast cancer was in the left side.
DISCUSSION
Mastectomy continues to be frequently required for the treatment of breast malignancies. An immediate reconstruction through a single-step breast implant offers the possibility to restore breast shape and volume harmonious with the body with a noninvasive and technically simple procedure.13 In the case of medium-large and ptotic breasts, the removal of excess skin after mastectomy becomes necessary to perform a prepectoral direct-to-implant. Such reduction allows reshaping of the breast envelope, also obtaining an improvement of the breast appearance compared with the presurgery condition. Also, the body image is better with a lift of the NAC in the correct place in case of a ptotic breast after breast reconstruction. However, it is essential to preserve vascularization for the NAC as much as possible.
In prepectoral breast reconstruction, interface materials are considered a prerequisite for state of the art, including preventing capsular contracture. ADM is frequently utilized but is expensive and associated with complications. Alternatively, a silicone implant coated with polyurethane foam can be utilized. In a variety of studies, polyurethane coating tended to be associated with fewer short-term complications than ADM, including seroma and infection, and the silicone implant coated with polyurethane is associated with a low incidence of capsular contracture, absence of implant rotation, and late seroma.14-16 One-stage immediate breast reconstruction with an anatomical implant with polyurethane covers after mastectomy appears to be oncologically safe, also showing a high level of patient satisfaction.17 In order to quantify the level of patient satisfaction after breast surgery, Breast-Q was developed for breast reconstruction.18
The strengths of our technique are listed below:
It is a single-stage breast reconstruction using anatomical implants, without the need to do a 2-stage reconstruction and without the use of ADM for reconstruction.
It is a prepectoral reconstruction without the need to lift the pectoral muscle, which allows quicker recovery in terms of pain and convalescence.
It is possible to correct breast ptosis by having a breast with a shape and size that is more suited to the chest and characteristics of the patient.
Preservation of the NAC is achieved without the need for a graft, therefore resulting in an improved cosmetic outcome.
The risk of necrosis of the mastectomy flaps and of the NAC is drastically reduced, even in active smokers, because access from the lower lateral triangle of the Wise pattern allows maintaining almost all the vascular connections (medial, superior, inferior, and lateral), in particular the fifth and the second intercostal perforators.19
The surgical access to perform the mastectomy is adequate and safe to remove the entire gland, even in the presence of medium-large and ptotic breasts.
It is a quick procedure and not expensive procedure.
It is a technique that satisfies both the patient and the surgeon regarding the aesthetic aspect, having minimal impact on the psychological aspect of the patient. Greater physical well-being at Breast-Q was statistically significantly correlated with a higher BMI as well as a higher volume of the implant.
It is possible to symmetrize the other breast at the same time as the mastectomy with mastopexy or breast reduction.
Unfortunately, our study has some limitations: the number of cases is small, and the Breast-Q questionnaire was not performed before the surgery. Lipofilling, a quick and straightforward procedure, will be necessary a few months later to resolve rippling. However, there is no animation deformity pain or functional limitation, given that the reconstruction is in the prepectoral plane.20-22
In the literature, there are many surgical techniques for breast reconstruction, both autologous and heterologous, but the trend is toward single-stage prepectoral reconstruction because of its benefits both in terms of complications and patient satisfaction.23-27 Some authors have reported their experience of breast reconstruction regarding skin reshaping after mastectomy in large and ptotic breasts.28,29
Breast surgery involves a multidisciplinary approach, with many specialists collaborating to guarantee the patient the best care and reconstruction.
CONCLUSIONS
Our experience with mastectomy from the lower lateral triangle of the Wise pattern, combined with direct prepectoral reconstruction using polyurethane-covered anatomical implants, suggests that this novel approach may offer a valuable option for women with medium-to-large and ptotic breasts. Our technique appears to allow immediate prepectoral reconstruction while potentially minimizing the risks of skin necrosis associated with skin reduction and maintaining an appropriate NAC position. Early results indicate that it could be a reproducible method leading to aesthetically pleasing outcomes and satisfaction for both patients and surgeons. Nevertheless, larger studies with longer follow-up are needed to confirm these findings and to compare this approach with other reconstructive techniques in breast ptosis.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.
REFERENCES
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