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      Is Open Access

      Trans-Vertical Mastectomy With Immediate Implant-Based Reconstruction: A Retrospective, Observational Study

      , MD 1 , , MD 2 , , MD 3

      Aesthetic Surgery Journal

      Oxford University Press

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          Abstract

          Background

          In women with large and ptotic breasts who require a mastectomy and immediate, implant-based reconstruction, long flaps pose a high risk for flap ischemia and necrosis. A new trans-vertical incision for skin-reducing mastectomy is described, which reduces the skin envelope and lifts the breast.

          Objectives

          The authors sought to describe the new mastectomy access incision and assess its efficacy and safety when followed by immediate implant-based reconstruction.

          Methods

          This retrospective analysis included 70 consecutive patients (101 breasts) with large and ptotic breasts who underwent a unilateral (n = 39; 55.7%) or bilateral (n = 31; 44.3%), skin-reducing mastectomy utilizing the trans-vertical approach for either breast cancer or risk reduction. All received immediate one- (n = 86; 85.5%) or two-stage (n = 15; 14.5%), implant-based reconstruction utilizing acellular dermal matrix.

          Results

          Mean age was 50.1 years and mean body mass index was 25.6 kg/m 2. After a median follow-up of 4.9 years, the number of breasts with minor and major complications was 21 (20.8%) and 26 (25.7%), respectively. The most common major complications were skin-flap necrosis (n = 12; 11.9%) and infection (n = 8; 7.9%). All occurred within 3 months postsurgically. There were 7 cases of capsular contracture (6.9%) and 5 reconstruction failures (5.0%). Higher body mass index ( P < 0.01) and breast weight ( P < 0.05) were associated with increased complication rates. According to BREAST-Q, 55/64 patients (85.9%) were somewhat or very satisfied with the aesthetic outcome.

          Conclusions

          The trans-vertical approach is an effective, reproducible, and safe alternative to conventional skin-reducing mastectomy, with favorable aesthetic outcomes, in patients with large and ptotic breasts.

          Level of Evidence: 4

          Related collections

          Most cited references 27

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          Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal matrix: indications, complications, trends, and costs.

          Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix optimizes aesthetics by preserving the mastectomy skin envelope. The authors report trends, early complications, and costs. A retrospective review of three surgeons' experience was performed for immediate single-stage implant reconstruction with acellular dermal matrix and tissue expander reconstruction without it at Massachusetts General Hospital. Two hundred eleven patients had 331 direct-to-implant reconstructions using AlloDerm following nipple-sparing (n = 66) or skin-sparing (n = 265) mastectomy for cancer (n = 216) or prophylaxis (n = 115). The number of single-stage implant reconstructions increased from seven in 2006 to 116 in 2009. The percentage performed for prophylaxis increased from 29 percent to 41 percent. Fifty-one patients underwent preoperative (n = 33) or postoperative (n = 18) irradiation. Total complications included 10 infections (3.0 percent), five seromas (1.5 percent), four hematomas (1.2 percent), and 30 reconstructions (9.1 percent), with skin necrosis leading to five implant losses (1.5 percent). Tissue expander reconstruction without AlloDerm had a similar total complication rate (158 reconstructions) (p = 0.18), including nine infections (5.7 percent), three seromas (1.9 percent), three hematomas (1.9 percent), and 16 reconstructions (10.1 percent), with skin necrosis leading to 11 implant losses (7.0 percent). A higher complication rate occurred in the surgeons' combined first year performing single-stage implant reconstruction (21.4 percent) compared with subsequent years (10.9 percent) (p < 0.02) and in one- or two-stage reconstruction patients undergoing irradiation (p = 0.005). There was no significant difference in total overall costs (p = 0.8). Immediate single-stage implant reconstruction using acellular dermal matrix offers a cost-effective reconstruction with a low complication rate. This may be the procedure of choice in select patients. Therapeutic, III.
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            An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm).

            The advent of skin- and nipple-sparing mastectomy in conjunction with the use of human acellular dermal matrix to provide lower pole coverage has made direct-to-implant immediate breast reconstruction following mastectomy feasible. The purpose of this study was to evaluate long-term complications associated with this technique. All human acellular dermal matrix-assisted direct-to-implant immediate reconstructions performed over an 8-year period were included in this analysis. Patient charts were reviewed for type of mastectomy (oncologic or prophylactic), incision type, complications during follow-up, length of follow-up, rate and type of revision surgery in breasts without postoperative complications, contralateral procedures, and adjuvant radiotherapy. A total of 466 breasts (260 patients) were reconstructed; 68 percent were prophylactic and 32 percent were oncologic cases. Twenty-one breasts (4.5 percent) received radiotherapy. Mean implant size placed was 412.8 ± 24.7 cc (range, 150 to 600 cc). Mean follow-up was 28.9 ± 21.3 months (range, 0.3 to 97.7 months). The overall complication rate was 3.9 percent (implant loss, 1.3 percent; skin breakdown/necrosis, 1.1 percent; hematoma, 1.1 percent; human acellular dermal matrix exposure, 0.6 percent; capsular contracture, 0.4 percent; and infection, 0.2 percent). Type, incidence, and overall rate of complications did not differ significantly between prophylactic and oncologic breasts. Irradiated breasts had a fourfold higher rate of complications. In 354 breasts with more than 1 year of follow-up (mean, 36.7 ± 18.6 months; range, 12.1 to 97.7 months), there were no long-term complications. Human acellular dermal matrix-assisted direct-to-implant breast reconstruction following mastectomy is safe and reliable, with a low overall long-term complication rate. The low incidence of capsular contracture supports the growing body of evidence that human acellular dermal matrix mitigates capsular contracture.
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              Breast Reconstruction after Breast Cancer

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                Author and article information

                Journal
                Aesthet Surg J
                Aesthet Surg J
                asj
                Aesthetic Surgery Journal
                Oxford University Press (US )
                1090-820X
                1527-330X
                June 2019
                24 July 2018
                24 July 2018
                : 39
                : 7
                : 733-742
                Affiliations
                [1 ]Assuta Medical Center, Tel Aviv, Israel
                [2 ]Shaare Zedek Medical Center, Jerusalem, Israel
                [3 ]Assuta Medical Center, Tel Aviv, and Kaplan Medical Center, Rehovot, Israel
                Author notes
                Corresponding Author: Dr Michael Scheflan, Raoul Wallenberg 18, Tel Aviv, Israel 69710. E-mail: michael@ 123456scheflan.co.il
                Article
                sjy181
                10.1093/asj/sjy181
                6594202
                30052751
                © 2018 The American Society for Aesthetic Plastic Surgery, Inc.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 10
                Product
                Funding
                Funded by: Integra LifeSciences
                Categories
                Breast Surgery
                Original Article

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