Single-Stage Mastopexy with Broad-Based Inferior Dermal Pedicle in Nipple-Sparing Mastectomy with Immediate Reconstruction for Large, Ptotic Breasts

Abstract

This paper introduces a novel approach to breast reconstruction in ptotic breasts undergoing nipple-sparing mastectomy (NSM). The technique integrates single-stage mastopexy with a broad-based inferior dermal pedicle and immediate reconstruction, inspired by the Boston Modified Robertson technique. It addresses the concerns of nipple viability as well as postoperative aesthetics compared with conventional mastopexy techniques.

The case report describes a 41-year-old woman diagnosed with left breast carcinoma who underwent a left NSM, followed by single-stage mastopexy with a broad-based inferior dermal pedicle and immediate pedicled transverse rectus abdominis myocutaneous flap reconstruction.

The approach resulted in favorable outcomes, including preserved nipple viability, high aesthetic satisfaction, and minimal complications.

Advantages over traditional methods include elimination of a vertical scar component, avoidance of free nipple grafting, and precise control of the distance between the nipple-areolar complex and inframammary fold, thereby enhancing breast shape.

Introduction

Nipple-sparing mastectomy (NSM) has been gaining popularity as an option for early breast cancer patients, with good oncologic safety in appropriately selected populations^1,2). However, patients with large or ptotic breasts are often considered poor candidates for NSM because of the increased risk of nipple necrosis and the difficulty of resizing and repositioning the nipple-areolar complex (NAC) to achieve optimal aesthetic outcomes³⁾.

This paper presents a novel approach to NSM in ptotic breasts with single-stage mastopexy and immediate reconstruction using a broad-based inferior dermal pedicle, adopting the principles of the Boston Modified Robertson technique (BMRT).

Robertson first described the technique of inferior flap mammaplasty in 1964, eliminating the need for a vertical scar compared to the Wise skin pattern⁴⁾. Hurst et al.⁵⁾ modified the technique in 1983 by eliminating the need for a free nipple graft and preserving the nipple on a dermal pedicle extending from the inferior flap. Movassaghi et al.⁶⁾ further modified this technique in 2006 into the BMRT, which eliminated the transverse scar across the mid-axis of the breast and positioned the transverse scar along the inferior portion of the breast, making it more concealable. A similar technique was adopted for the treatment of pseudogynecomastia by Hardy et al.⁷⁾, in which 5 to 10 mm of subdermal fat was preserved on a dermal pedicle based on the entire inframammary fold (IMF). We further adapted this technique for NSM in large, ptotic breasts.

The use of this novel technique in the setting of NSM confers several advantages, including the ability to preserve a vascularized nipple and avoid a free nipple graft while achieving simultaneous breast skin reduction with a reliable skin pocket. By avoiding a conventional free nipple graft, nipple sensation can be preserved. The technique also allows for more than 10 cm of nipple movement in large ptotic breasts, resulting in better aesthetic outcomes.

Case Presentation

Written informed consent

Written consent was obtained, in which the patient agreed to the use of her clinical photographs. Institutional Review Board approval was not required for this case report.

Demographic and background

The patient is a 41-year-old female who presented with a left breast lump of 2 months' duration. Ultrasound of the left breast revealed few hypoechoic, irregular masses, all connected by tentacle-like extensions, measuring approximately 5.5 cm in size, located at the 1-2 o'clock position. Core biopsy confirmed invasive carcinoma of no special type that was estrogen-receptor and progesterone-receptor positive, and human epidermal growth receptor-2 negative. Preoperative staging scans showed no definite distant metastasis. Based on recommendations from the multidisciplinary team meeting and after discussions with the patient, a left NSM with sentinel lymph node biopsy and immediate pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was planned.

Breast reconstruction considerations and planning

The patient had bilateral G cup breasts with Regnault Grade III ptosis (Figure 1) and a sternal notch-to-nipple distance of 15 cm bilaterally. Her right and left NAC diameters were 11.5 cm and 11.0 cm, respectively.

Figure 1.

Preoperative clinical photographs—bilateral G cup breasts with Regnault Grade III ptosis.

Given her large, ptotic breasts, a left NSM with single-stage mastopexy using a broad-based inferior dermal pedicle was planned. She was also counseled on the possibility of conversion to a free nipple graft if intraoperative assessment showed compromised NAC vascularity. To optimize aesthetic outcomes and breast symmetry, staged contralateral breast reduction for symmetrization was also planned.

Preoperative markings are shown in Figure 2a.

Figure 2.

a. Preoperative markings.

b. Preoperative marking illustration and guidelines. Image on the right showing the broad-based inferior dermal pedicle with the de-epithelialized flap within the breast pocket.

The new nipple position is first determined using Pitanguy's point⁸⁾, and the desired new NAC diameter is marked. An elliptical transverse breast pocket reduction incision incorporating the original NAC is designed. The upper border of the incision is placed approximately 1 cm above the original NAC. We recommend maintaining a distance of at least 5 cm between the inferior border of the new NAC and the superior skin incision to maximize skin flap perfusion. The ideal new nipple-to-IMF distance is predetermined―in this case, a 10 cm distance was chosen for her breast size. The lower border of the incision is then marked using the following equation (Figure 2b):

(Distance from inferior border of new NAC to superior skin incision) + (Distance from inferior skin incision to IMF) = New nipple-to-IMF distance

Lastly, a broad inferiorly-based dermal pedicle is marked.

Operative technique

The NAC was first reduced to 4.5 cm. The broad inferiorly-based dermal pedicle was carefully de-epithelialized (Figure 3). The upper incision was made, and the surgery was handed over to the breast surgeon to perform the mastectomy.

Figure 3.

The broad inferiorly-based dermal pedicle is first de-epithelialized.

The mastectomy specimen weighed 1,022 g. Concurrent with the mastectomy, the ipsilateral TRAM flap was raised based on the deep superior epigastric pedicle, preserving medial and lateral row perforators.

Indocyanine green (ICG) fluorescence imaging was performed, which showed good perfusion of the mastectomy skin pocket and NAC. The ICG protocol adopted involved 15 mg of ICG given intravenously. The ICG fluorescence imaging was used to examine perfusion of the mastectomy skin flap and NAC at the 2-minute mark. If there was no perfusion over the NAC after 2 minutes and no bleeding on pinprick, a free nipple graft would be considered.

A tunnel was created over the medial IMF, and the flap was delivered into the left breast pocket, shaped and completely de-epithelialized (Figure 4). The inferior dermal pedicle was secured to the TRAM flap using absorbable sutures. The superior skin flap was then stapled to the inferior skin incision, and the neo-nipple opening was created on the superior skin flap. The neo-nipple-to-IMF distance measured 10 cm. The operative technique is illustrated in sequential order in Figure 5.

Figure 4.

Mastectomy is performed through the upper incision, and the de-epithelialized flap is placed in the breast pocket.

Figure 5.

A: Preoperative markings: new NAC position (dotted circle), IMF (dotted straight line), superior incision (curved dotted line). B: Post NSM through superior incision; inferior dermal pedicle de-epithelialized; NAC reduced to optimal size. C: De-epithelialized TRAM flap (dotted oval) tunneled and inset into mastectomy skin pocket. D: NAC inset into new NAC position with inferior dermal pedicle tucked under the superior skin flap.

IMF: inframammary fold; NAC: nipple-areolar complex; NSM: nipple-sparing mastectomy; TRAM: transverse rectus abdominis myocutaneous flap

The TRAM donor site rectus sheath was repaired and reinforced with a mesh. The abdomen was then closed. On-table results are shown (Figure 6). Glyceryl trinitrate (GTN) patches were placed because of mild congestion of the inferior NAC skin bridge.

Figure 6.

On-table results showing mild congestion over the skin bridge inferior to the NAC.

NAC: nipple-areolar complex

Postoperatively, the patient was discharged 5 days later. Mild epidermolysis was noted over a 1 × 1 cm area of the skin bridge inferior to the NAC, which healed with conservative management using simple dressings within 2 weeks. There were no signs of overt NAC necrosis, and there was 100% survival of the NAC.

The final histology of the mastectomy specimen revealed grade 1 invasive carcinoma of no special type (ductal), estrogen-receptor and progesterone-receptor positive, and human epidermal growth receptor-2 negative, with nipple base and subareolar region clear of invasive carcinoma―staged at pT2 N1 Mx according to the American Joint Committee on Cancer breast cancer staging criteria⁹⁾.

Her postoperative results at 2 months are shown (Figure 7). Subsequently, the patient underwent chemotherapy, and radiotherapy, and right breast symmetrization procedures, with results at 2.5 months and 1 year postsymmetrization (Figure 8 and 9). At the 1-year follow-up, the patient reported recovery of sensation over the peripheries of the nipple. The Semmes-Weinstein monofilament test, 2-point discrimination test, and cold sensation test were carried out 1 year after reconstruction. The Semmes-Weinstein monofilament test was performed with a 10-g monofilament. The sensation tests revealed that the reconstructed nipple had partial recovery of NAC sensation to gross touch and temperature sensation but not fine touch, such as from the monofilament. Overall, the patient was satisfied with the reconstruction and mammoplasty outcomes.

Figure 7.

Results at 2-months postoperation.

Figure 8.

Results at 2.5 months postsymmetrization procedure.

Figure 9.

Results at 1 year postsymmetrization procedure.

Discussion

The BMRT has been used successfully for breast reduction mammoplasty in large ptotic breasts⁶⁾. However, its adoption in a single-stage procedure with NSM has not been previously described. The authors propose this novel approach to address the unique challenges of managing large, ptotic breasts during NSM while preserving nipple viability and achieving optimal aesthetic outcomes.

Several techniques have been previously proposed for NSM in ptotic breasts, each with distinct limitations (Table 1). Skin reduction mastectomy with free nipple grafting is a simple way to reposition the nipple to an ideal location on the reconstructed breast mound¹⁰⁾. However, mastectomy skin flaps with Wise skin-reduction pattern are prone to wound-healing problems at the inverted T-scars^11,12), while the free nipple graft produces a ‘stuck-on' and deflated appearance with dyspigmentation. Vertical dermal pedicles require folding of the pedicle on itself, which makes insetting difficult¹³⁾. Pontell¹⁴⁾ previously described reduction mastopexy in a single-stage procedure using a batwing-shaped supra-areolar incision and mobilizing the NAC based on an inferior, wide-based, epithelialized pedicle. However, this approach presents the problem of an uncorrected and less-than-ideal IMF to NAC distance and a transverse scar across the mid-axis of the breast. Additionally, enlarged NAC diameters cannot be reduced.

Table 1.

Comparison between Various Skin-Reduction and Nipple-Repositioning Techniques.

Technique	Advantages	Disadvantages
BMRT9)	Effective and reliable method in reduction of large ptotic breasts with sternal notch to nipple distance of more than 40 cm	Not as effective in reducing horizontal excess
	Avoids the needs for a free nipple graft
	Transverse scar is hidden well under the shadow of the inferior breast
Wise-Pattern resection	Allows for reduction of both vertical and horizontal excess	Prone to skin flap ischaemia and wound complications10)
		Compared to the BMRT, additional vertical scar component
Batwing-shaped supra- areolar incision8)	Preserves inferior based vascular supply to NAC	Scar across mid axis of breast
		Does not correct less-than-ideal NAC to IMF distance
		Not suitable for reduction of pendulous breasts

BMRT: Boston Modified Robertson technique; IMF: inframammary fold; NAC: nipple–areolar complex

The novel technique described in this paper utilizes a single incision for single-stage NSM and mastopexy for large, ptotic breasts. It successfully reduces the breast skin pocket while avoiding wound-healing problems associated with a Wise-pattern skin incision, especially at the trifurcate. It also allows control of the new nipple-to-IMF distance, which in our opinion, most significantly affects breast shape. Furthermore, by preserving a broad inferiorly-based dermal pedicle, the need for a free nipple graft is avoided. This technique offers a reliable option for the reduction of large, ptotic breasts while allowing recovery of nipple sensation.

The horizontal incision allows for excellent versatility across different reconstruction modalities. It can be employed in autologous reconstruction cases such as the one reported here―a pedicled TRAM flap―but also in free flap reconstructions, where it provides good exposure of the internal mammary vessels, which are common recipient vessels for anastomoses in free flap procedures (e.g. free deep inferior epigastric perforator flap). An alloplastic reconstruction with implants or tissue expanders is also an option, offering good access to the prepectoral or subpectoral plane. However, because the vascular support in alloplastic reconstructions may be less robust compared to pedicled or free flaps, there is a potentially increased risk of NAC compromise.

The authors propose careful patient selection to reduce risk of NAC necrosis, particularly avoiding smokers, patients with diabetes, and older patients. Gentle handling of skin flaps and the dermal pedicle to the NAC should also be emphasized. In this case report, the large mastectomy weight of more than 450 g and the presence of breast ptosis were identified as positive predictive indicators for NAC necrosis¹⁵⁾. To mitigate this risk, GTN patches were applied to the NAC postoperatively. The use of low-dose GTN patches has previously been shown to reduce the risk of skin flap necrosis after skin-sparing or NSM¹⁶⁾. In this case, there was 100% survival of the NAC (Figure 6 and 7).

The primary limitation of this technique is its inability to effectively reduce the horizontal breast width, which may make it less suitable for patients with larger initial breast width, as it could result in a “boxy” breast appearance. Hence, strong emphasis should be placed on proper patient selection when considering this technique.

Another limitation is the horizontal scar, which may not always be fully concealed within the IMF. A Wise-pattern incision is possible; however, as addressed in the paper, in the setting of mastectomy and especially with large breasts, the additional vertical incision increases the risks of wound-healing complications at the trifurcation compared with a single horizontal incision. Additionally, a horizontal incision provides superior surgical access for mastectomy compared with a vertical incision alone. Nonetheless, the horizontal scar may not always be concealed within the IMF and may require revision. In this case report, scar revision was discussed with the patient, but she declined.

Conclusion

This case report demonstrates the use of a broad-based inferior dermal pedicle for mastopexy in a single-stage procedure with ipsilateral NSM and immediate autologous breast reconstruction. This approach yielded good patient satisfaction and minimal postoperative complications. However, a larger cohort study is required to assess the consistency of outcomes when employing this novel technique.

Author Contributions: N.D.Y.: Writing - Original Draft, P.C.H., J.H.: Conceptualization, J.H.: Supervision, All authors: Writing - Review & Editing.

Conflicts of Interest: There are no conflicts of interest.

Ethical Approval: IRB was not sought for this case report as it does not involve any testing or experimentation on any individual.

Consent to Participate: The patient provided their written informed consent to participate in this study.

Consent for Publication: The patient provided their written informed consent to participate in this study.