Implant selection in natural and stable direct-to-implant reconstruction with ten steps at nipple-sparing mastectomy

Abstract

Direct-to-implant reconstruction is one of the breast repair techniques after mastectomy. Implant selection is critical in the short- and long-term success of direct-to-implant reconstruction after nipple-sparing mastectomy. In this study we developed a 10-step algorithm that we use before and during surgery. We aimed to obtain natural and stable breast reconstruction with this algorithm. In addition, we also aimed to evaluate which implants were selected using this algorithm and their short- and long-term outcomes. This retrospective study included 218 patients aged 27 to 60 years who underwent mastectomy and direct-to-implant reconstruction between November 2018 and December 2021. The patients were assigned into 4 groups according to amount of breast tissue removed. We developed a 10-step algorithm and these included: breast base, amount of breast tissue removed, evaluation of mastectomy skin flap, breast projection, ptosis, unilateral/bilateral reconstruction, chest wall deformity, patient's request, comorbid conditions and stabilization and arrangement of novel sulcus. The evaluation was made when the patient's photographs were taken at least 1 year after the surgery. The highest number of patients was recorded in group 3; in addition, mean age was also highest in group 3. The lowest number of patients was recorded in group 4. The body mass index showed a progressive increase from group 1 to group 4. Medium height moderate profile prosthesis was used in 81.7% while medium height moderate plus profile prosthesis was used in 18.3% of breasts included. We used larger prosthesis up to 58.1% when compared to the tissue removed in group 1 while we used smaller prosthesis by 25.6% in group 4. In the anterior view, the medial and lateral arch of the lower pole of the breast was obtained in all patients. Obvious asymmetry developed in 4 patients. In lateral and oblique views, upper and lower pole natural breast images were obtained in all patients, except for 5 patients. There was no sulcus inferior displacement in any patient. Implant extrusion did not occur in any patient. This algorithm is an easy to use and effective method to obtain a stable and natural breast image in the long-term.

Figure 1.

50-year-old multiparous with right breast cancer patient underwent bilateral NSM + direct-to-implant reconstruction. She has high-stiffness skin structure and asymmetric breast pattern and is in group 3. Reconstruction was performed with an IMF insicion. 490 cc of tissue from the right breast and 580 cc of tissue from the left breast were removed. Reconstruction with 480 cc medium height moderate profile anatomical implant. (A) Preoperative anterior view. (B) Preoperative oblique views. (C) Postoperative 14th month anterior view. The same model implant was placed on both breasts and postoperative good symmetry was achieved. There was a certain amount of shrinkage in the left breast. (D) Postoperative 14th month oblique view. IMF = Inframammary fold, NSM = Nipple-sparing mastectomy.

Figure 2.

41-year-old multiparous with left breast cancer patient underwent NSM + direct-to-implant reconstruction. She has high-stiffness skin structure and is in the group 1. Reconstruction was performed with an IMF incision. 186 cc of tissue was removed from each breast. Medium height modorate profile 280 cc implant was used for both breasts. (A) Preoperative anterior view. (B) Preoperative oblique view. (C) Preoperative lateral view. (D) Postoperative 12th month anterior view. In the medial and lateral quadrants, it is seen that the natural breast curve of the breast is formed and good symmetry was achieved. (E) Postoperative 12th month oblique view. IMF incision scar is shown. (F) Postoperative 12th month lateral view. It was shown that the lower and upper quadrants of the breast were formed in the Figure 2E and Figure 2F. Also, the location, stabilty and symmetry of the inframmaryal sulcus are shown. IMF = Inframammary fold, NSM = Nipple-sparing mastectomy.

Figure 3.

60 years old multiparous with left breast cancer patient underwent NSM + direct-to-implant reconstruction. She has low-stiffness skin structure and is in the group 3. Reconstruction was performed with an lateral curved incision. 640 cc of tissue was removed from the left breast. Breast reconstruction with medium height modorate profile 530 cc implant was done. (A) Preoperative anterior view. (B) Preoperative oblique views. (C) In the postoperative 26th month image, it was shown that medial and lateral quadrant of the breast was created. A certain amount of reduction was seen in the left breast. Symmetry is not fully achieved. (D) In the postoperative 26th month oblique view, it was shown that the upper pole and lower pole were formed. The location of the lateral incision is also shown in this image. NSM = Nipple-sparing mastectomy.