Breast reconstruction after nipple-sparing mastectomy in the large and/or ptotic breast: A systematic review of indications, techniques, and outcomes

Abstract

Background: Surgeons remain reluctant to perform nipple-sparing mastectomy (NSM) in large breasts due to a higher risk of necrosis. We performed a systematic review of the literature to evaluate indications, techniques, and outcomes in immediate or delayed breast reconstructions in large and/or ptotic breasts.

Methods: The following search terms were used for both titles and key words: [NSM AND ("breast ptosis" OR "ptotic breast" OR "large breast" OR "breast hypertrophy" OR "gigantomastia")]. All forms of breast reconstruction in large and/or ptotic breasts from 1990 through September 1st 2018 reporting indications, techniques, and outcomes were included.

Results: Thirty-one studies met the inclusion criteria, yielding 1128 NSMs (709 immediate and 419 delayed) in 629 patients for analysis. The overall complication rate was 29.08%. The mastectomy flap necrosis rate was 12%, the partial nipple-areola complex (NAC) necrosis 11%, and the complete NAC rate 11%. The overall complication rate in one-stage versus delayed reconstructions was 37.52% versus 14.8%. The incidence of necrosis in one-stage versus delayed reconstructions was 5.36% versus 2.15% for partial, 5.08% versus 0.48% for complete NAC necrosis, and 4.8% versus 1.43% for skin flap necrosis.

Conclusions: The majority of studies being small and retrospective as well as the large variation in outcomes indicates that we lack consensus on the timing of reconstruction or ideal technique. A noticeable difference in skin flap and NAC necrosis, however, is seen in the favor of NAC-delayed procedures. Randomized controlled trials are mandatory to prove this difference significantly.

Keywords: Delayed breast; Nipple delay; Nipple necrosis; Nipple-sparing mastectomy; Preshaping of the breast; Reconstruction.