Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques

Sir: We read with interest a recent article by Mosharrafa et al. entitled “Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques.”1 The authors describe their experience with a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy. We have also utilized this single-stage technique and agree that excellent results can be obtained in a selected group of patients without the disadvantage of performing multiple operations.2 However, we have noted some limitations of this approach. First, we found this technique to be unreliable in patients with a nipple-areola complex–to–inframammary fold distance greater than double the inframammary fold width. Thus, patients with narrow breasts or those with moderate to severe ptosis may not be good candidates. Second, this technique requires a team approach with an experienced breast surgeon. At our institution, for example, the breast surgeon usually elevates the inferior flap off of the breast parenchyma. Careful nipple-areola complex dissection at this point in the operation is a critical step to optimally preserve vascularity. If the flap is too thin, viability of the nipple-areola complex will be jeopardized. For patients deemed suboptimal candidates for this technique, such as those mentioned above, we have developed two alternative modifications that can be utilized reliably and successfully. The first is based on an inferiorly based adipodermal flap. If the pedicle is too long or too thin or if the nipple-areola complex needs to be resected for oncological safety, a round skin paddle can be designed closer to the inframammary fold to serve as a neoareola. [See Figure, Supplemental Digital Content 1, which shows single-stage direct-to-implant reconstruction of a ptotic breast combined with a mastopexy-like procedure. In this case, the nipple-areola complex was not able to be preserved given oncologic safety. Areola reconstructions were performed using wide, inferiorly based adipodermal flaps. (Above) Preoperative markings. (Below, left) Elevated inferiorly based adipodermal flaps with preserved round skin paddle to serve as a neoareola. (Below, right) Intraoperative appearance of reconstructed breasts after closure, https://links.lww.com/PRS/E494.] Then the flap distal to this neoareola is amputated and prepectoral direct-to-implant reconstruction is completed in a fashion similar to that described by Mosharrafa et al.1 This is a modification of a technique previously described for lumpectomy defects and breast reductions.3,4 We have performed multiple bilateral reconstructions using this technique with favorable outcomes. The majority of our patients were pleased with results and did not wish to undergo further nipple reconstruction. The second technique allows preservation of the nipple-areola complex even if the nipple-areola complex–to–inframammary fold distance exceeds the breast width by twofold.5 In this technique, a superior adipodermal pedicle is utilized as opposed to the inferior pedicle. [See Figure, Supplemental Digital Content 2, which shows single-stage direct-to-implant prepectoral reconstruction of a ptotic breast combined with a mastopexy-like procedure. The nipple-areola complex is based on a superior adipodermal flap. (Above, left) Preoperative markings. (Below) Mastectomy flap with a superior adipodermal pedicle. (Above, right) Intraoperative appearance of reconstructed breasts after closure, https://links.lww.com/PRS/E495.] Wise-pattern markings are made, and the skin is deepithelialized. A nipple-sparing mastectomy is then performed through the inframammary incision. Acellular dermal matrix is sutured in a prepectoral position and an implant sizer is placed. Then the breast is closed in a mastopexy-like fashion, followed by exchange of the sizer to a permanent implant. As of this writing, we have performed 38 bilateral reconstructions of this type, with a favorable complication profile and a high level of patient-reported satisfaction.5 In conclusion, we find the single-stage technique described by Mosharrafa et al. very useful in selected patients. If, for the reasons mentioned above, it cannot be utilized, we present additional single-stage alternatives that in our experience can yield excellent outcomes and satisfied patients. DISCLOSURE Dr. Moreira is a compensated speaker for Acelity. All other authors have no commercial associations or financial disclosures to report. Grzegorz J. Kwiecien, M.D.Demetrius M. Coombs, M.D.Cagri Cakmakoglu, M.D.Steven Bernard, M.D.Department of Plastic and Reconstructive Surgery Alicia Fanning, M.D.Department of General SurgerySection of Breast Surgery Andrea Moreira, M.D.Department of Plastic and Reconstructive SurgeryCleveland ClinicCleveland, Ohio