Review
A systematic review of complications associated with direct implants vs. tissue expanders following Wise pattern skin-sparing mastectomy

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Summary

Introduction

With proven oncological safety and improved aesthetic outcomes, the Type IV or “Wise pattern” skin-sparing mastectomy (SSM) is a procedure that is being performed with increasing frequency. Unfortunately, it is also associated with an increased risk of complications. The purpose of this investigation was to determine the complications associated with direct-to-implant and two-step tissue-expander breast reconstruction following Wise pattern SSM.

Methods

Systematic electronic searches were performed using PubMed, MEDLINE, and Embase databases. Search terms used were those for studies reporting complications following breast reconstruction using direct-to-implant and two-step tissue-expander approaches following Wise pattern SSM. Included studies were graded for their risk of bias. Pooled descriptive statistics on overall complication rates, skin flap necrosis, delayed wound healing, hematoma, and infections were performed for both procedures. Other complications specific to each procedure were also reported.

Results

A total of 16 articles met the inclusion criteria for this investigation, representing 561 direct-to-implant or two-step breast reconstruction procedures. For direct-to-implant reconstructions, the pooled complication rate was 30%, while for those using tissue expansion, it was 20.3%. Rates of skin flap necrosis (9.70%, 4.69%), delayed wound healing (2.77%, 0.78%), infection (2.54%, 3.91%), seroma (1.15%, 4.68%), and hematoma (0.92%, 0.78%) were calculated for direct-to-implant procedures and two-step tissue expansion, respectively.

Conclusion

Following Wise pattern SSM, direct-to-implant reconstruction appears to be associated with an increased rate of overall complications and skin flap necrosis. Modification of the procedure through the placement of a de-epithelialized dermal flap may help limit delays in wound healing and infection. Future investigations that report complication rates for SSM should present data that are segregated according to the type of procedure and the method of reconstruction.

Introduction

Skin-sparing mastectomy (SSM) is being used with increasing frequency in the surgical management of breast cancer.1, 2 Initially described by Toth and Lappert, SSM involves excision of the breast, nipple–areola complex, previous biopsy incisions, and any skin overlying superficial tumors while attempting to preserve the native breast skin.1, 2 The result is a procedure that leads to superior aesthetic outcomes for post-mastectomy breast reconstruction, compared to traditional total mastectomy, with similar oncological safety.1, 2, 3, 4

With regard to technique, SSM can be subdivided into four different subtypes.1, 2 Type I SSM, used for prophylactic surgeries or nonpalpable cancers, involves a peri-areolar incision that can be extended with a lateral “tennis racquet” incision to facilitate breast tissue removal and reconstruction.1, 2 Type II SSM is employed when the site of biopsy or a superficial tumor is in proximity to the areola, necessitating a peri-areolar incision that incorporates these features.1, 2 Conversely, Type III SSM is indicated when the site of biopsy or superficial tumor is not in proximity to the areola, requiring two separate incisons.1, 2 Finally, for large ptotic breasts, Type IV SSM is usually employed.1, 2 This procedure involves the creation of an inverted T or a “Wise-pattern” incision that encompasses the areolar complex, a vertical incision, and a final incision along the infra-mammary fold.1, 2 Although Type IV SSM is the optimal approach for certain patients, especially those who desire excision of excess skin and subsequent breast reduction, the Wise pattern incision is associated with a higher incidence of postoperative complications.1, 4 For example, the limited vascularity of the distal parts of the flaps combined with biomechanics of the T-junction produced by this process can result in problems with skin flap necrosis and delayed wound healing.1, 2, 3, 4

The reconstructive surgeon must take all necessary precautions to ensure the best clinical outcome. However, a challenge faced in the reconstructive process using the Wise pattern incision is the decision to perform a one-stage direct-to-implant procedure or a two-stage procedure, where a tissue expander is employed. Although the one-stage approach involves fewer operative steps, the placement of a larger implant without initial expansion can increase the risk of vascular compromise.5

The purpose of the study was to systematically review the literature to determine and compare the complication rates associated with one-stage breast reconstruction compared to two-stage reconstruction following Type IV SSM. Because of the paucity of literature on the subject, complications associated with each procedure were evaluated to consolidate the limited data and facilitate clinical decision-making.

Section snippets

Data sources and search strategy

To catalog the literature on outcomes following Type IV mastectomy with reconstruction, a search of the National Library of Medicine (PubMed), Embase: biomedical database, and MEDLINE databases was performed using the search strategy. The search was limited to papers published in peer-reviewed journals, involving human subjects, and written in English. SSM was introduced in 1991 (Toth & Lappert); thus, only papers published since 1991 were included. The following search terms were used in the

Results

Of the 590 original articles, 10 met the inclusion criteria for the review (Figure 1). Following the citation search, six other articles were found, resulting in a total of 16 studies meeting the inclusion criteria (Figure 1).6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 These manuscripts contain data collected from 561 direct-to-implant or two-step breast reconstruction procedures following type IV (Wise pattern) SSM. Information on study type, patient demographics, type of

Discussion

SSM has become an increasingly popular mastectomy modality among patients and surgeons secondary to proven oncological safety and superior aesthetic results.1, 2, 3 The preferential aesthetic outcome following SSM is a result of the preservation of the native skin, the reduced amount of autologous skin needed for reconstruction, and the increased ability to shape the breast mound.22 However, despite growing interest, to date, there are limited data on the complications associated with

Conclusion

Following Wise pattern SSM, direct-to-implant reconstruction appears to be associated with an increased rate of overall complications vs. delayed reconstruction (30.3% vs. 20%). Modification of the procedure through the placement of a de-epithelialized dermal flap may help limit delays in wound healing and infection. Future investigations that report complication rates for all types of SSM should present data that are segregated according to the type of procedure and the method of

Financial disclosures

None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Conflict of interest

None of the authors have any known conflict of interest.

Contribution of authors

Dr. Jason Corban provided the original idea. He was involved in data collection, study planning, and manuscript write-up.

Dr. Hani Shash supported original idea. Involved in data collection and manuscript writing and editing.

Tyler Safran was involved in the review of the literature and the data collection. He was also involved in the manuscript write-up and the submission and revision of the manuscript.

Nicolas Sheppard-Jones was involved in review of the literature and data collection. He was

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