Description of a Novel Technique: Utilizing a De-Epithelialized Inferior Mastectomy Skin Flap to Preserve the Nipple-Areolar Complex in Patients with Stage II and III Breast Ptosis
Breast cancer is the most common malignancy diagnosed in women aside from non-melanoma skin cancer with 276,480 new cases of breast cancer estimated to be diagnosed by the end of 2020.1 Recently nipple sparing mastectomy (NSM) has become more common due to improved cosmesis and low rate of tumor recurrence.2 However, this can prove challenging in women with grade II or grade III breast ptosis due to difficulty with adequate positioning of the nipple-areolar complex (NAC) and its compromise of vascular supply. Staged mastectomy through a combination of autologous tissue flaps and surgical delay has been described in order to combat the risk of nipple necrosis.3-4 However, that technique provides a method of preserving the NAC that pertains to autologous based reconstructions, and the NAC is not positioned until the second stage. Our study describes a novel technique of utilizing a de-epithelialized inferior mastectomy skin flap to preserve the vascular supply to the NAC and allow adequate positioning during the first stage of an expander-based reconstruction on patients with grade II and grade III breast ptosis. _ To briefly describe the technique, a preoperative Wise pattern marking is placed as a guideline for the NSM. After completion of a standard mastectomy the remaining inferior mastectomy skin flap is deepithelialized. The viability of the inferior mastectomy skin flap and the NAC is then assessed with SPY Elite fluorescence imaging following intravascular administration of indocyanine green. If well perfused, the NAC is then marked and modified to the desired circumference and size. The wise pattern is closed over the either prepectoral or subpectoral expander based reconstruction. The preserved NAC is the externalized. Our study includes 9 consecutive patients performed from July 2019 to December 2019, with a total of 18 breasts included in the study. 89 percent of the salvaged NACs remained viable throughout the reconstruction, with only 1 NAC with postoperative partial NAC necrosis. This study provides a novel technique for preservation of the NAC in patients with grade II and grade III ptosis undergoing expander-based reconstruction after a wise pattern NSM.