Journal of Plastic, Reconstructive & Aesthetic Surgery
ReviewA systematic review of complications associated with direct implants vs. tissue expanders following Wise pattern skin-sparing mastectomy
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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Cited by (35)
Prediction model for haematoma after tissue expander placement: A retrospective cohort study of 7080 cases over 20 years
2024, Journal of Plastic, Reconstructive and Aesthetic SurgeryWisepatern mastopexy for natural breast ptosis symmetrization after giant lipoma excision: Case report
2023, International Journal of Surgery Case ReportsImmediate fine-tuning of DIEP flaps using the Wise pattern mastectomy: Description of the technique and a retrospective analysis of complication rates
2022, Annales de Chirurgie Plastique EsthetiqueCitation Excerpt :The use of Wise pattern incisions for mastectomies in patients with large breasts was first described in 1991 by Toth and Lappert where they used the pattern to reduce the skin envelope of patients undergoing mastectomies and immediate reconstructions with either tissue expanders or TRAM (transverse rectus abdominis muscle) flaps [11]. The Wise pattern mastectomy has since been described extensively in large-breasted patients undergoing immediate reconstruction with expanders or implants and is believed to provide superior results to the traditional elliptical mastectomies in this patient population [9,12–14]. We advocate using this pattern for mastectomy instead of the elliptical pattern for large and ptotic breasts requiring DIEP flap reconstruction to achieve good DIEP shape, size, and aesthetic results in these patients, without the need for subsequent revision surgery to reduce the DIEP flap or its skin envelope (Fig. 2).
Impact of demographic and perioperative risk factors on complication rates in skin-sparing/nipple-sparing mastectomy with implant-based reconstruction using titanized polypropylene mesh (TiLOOP® Bra)
2022, Surgical OncologyCitation Excerpt :In particular, T-incision in combination with mastopexia is often necessary in larger breasts to achieve an adequate aesthetic result, but carries an increased risk of necrosis. Furthermore, we could show that expanders have no significant advantage in terms of necrosis or wound healing delay rates, which is controversial in literature [34–36]. However there is a trend towards more wound healing delays with permanent implants (p-value = 0.134).
Breast Reconstruction
2021, Plastic Surgery - Principles and PracticeA retrospective review of breast reconstruction outcomes comparing AlloDerm and DermaCELL
2019, JPRAS OpenCitation Excerpt :A larger review of more than 2000 ADM reconstructions revealed a pooled rate of nearly 5% for infection.26 Corban et al. found that the Wise pattern with direct to implant had higher rates of MFN.25 Our MFN rate was 8.4%, which is lower than the documented rates at our institution, but this will have been influenced by our use of nitroglycerin paste.20