The reinforced pedicle technique: a case report of secondary mastopexy following nipple-sparing mastectomy with autologous breast reconstruction

Introduction

Immediate reconstruction after nipple-sparing mastectomy (NSM) can be either autologous or implant based. Autologous reconstruction, most commonly using the free deep inferior epigastric artery perforator (DIEP) flap, provides excellent aesthetic results in patients with NSM. However, difficulty arises if the patient has significant ptosis (greater than Regnault grade 2 or 3, as per Spear et al.) due to the excessive skin envelope and the potentially attenuated blood supply to the nipple areolar complex (NAC) (1,2). In this situation, the patient has two options: she either converts to a skin-sparing mastectomy (SSM), or she has a mammoplasty first to lift the NAC, followed by a delayed NSM and autologous reconstruction (2). The second option, whilst preserving the NAC, requires two surgeries. This is a good option for risk-reducing NSMs, but delaying the mastectomy is not oncologically safe in patients with cancer, and such patients are often committed to SSMs instead.

Here, we describe an innovative technique that allows the NAC to be safely raised after NSM and free-flap reconstruction. We hope that it will change the paradigm for women with breast cancer and ptotic breasts who choose autologous reconstruction, allowing them to undergo NSM rather than SSM. We present this case in accordance with the CARE reporting checklist (3) (available at https://gs.amegroups.com/article/view/10.21037/gs-24-109/rc).

Case presentation

A 34-year-old female was initially treated with wide local excision of ductal carcinoma in situ and mammoplasty of her left breast. Due to positive oncological margins, she then underwent left NSM and implant reconstruction (Motiva 425 cc anatomical implant with TiLoop Bra Pocket in the pre-pectoral plane). She had no other past medical history, was not on any regular medications, was a non-smoker and was negative on screening for hereditary breast cancer gene mutations. A year later, she underwent risk-reducing NSM of the right breast due to hereditary risk despite negative genetic screening. She elected for bilateral DIEP free flap reconstruction. Because she had previously undergone mammoplasty on her left side only, her preoperative nipple-to-sternal notch distance was 26 cm on the right, with Regnault grade 2 ptosis, and 22 cm on the left (Figure 1). Bilateral DIEP free flap surgery was uneventful. A vertical sub-areolar incision pattern was used for the mastectomy, leaving the native NAC intact. A patch of abdominal skin for free flap monitoring was inset here with a plan to excise it at a later operation. The vertical skin paddle was chosen because it is optimal for patients who have undergone previous breast reduction and for those with ptotic breasts (4,5). Following DIEP reconstruction, the patient’s nipple-to-sternal notch distance was 24.5 cm on the right and 22 cm on the left (Figure 2). Twelve months later, the patient underwent revision surgery using the reinforced pedicle technique to elevate her right NAC. She underwent liposuction and lipofilling during the same procedure.

Figure 1 Pre-operative photo of the patient prior to her bilateral deep inferior epigastric perforator flap reconstruction. She had undergone mammoplasty and wide local excision of ductal carcinoma in situ of her left breast, followed by nipple-sparing mastectomy and implant reconstruction. Her preoperative nipple-to-sternal notch distance was 26 cm on the right, with Regnault grade 2 ptosis, and 22 cm on the left.

Figure 2 The patient is shown 6 months post bilateral deep inferior epigastric perforator flap reconstruction. Her right reconstructed breast has Regnault grade 1 ptosis. Post-reconstruction nipple-to-sternal notch distance was 24.5 cm on the right and 22 cm on the left, as she had undergone previous mammoplasty on the left side only.

Standard breast reduction markings were performed preoperatively. A vertical skin excision pattern was marked, incorporating the monitoring paddle inferior to the NAC, which we planned to excise. The width was determined by the volume reduction required to symmetrize the reconstructed breasts. A vertical pedicle incorporating the NAC was marked. The periareolar epidermis was scored in two concentric rings, and a ring of epidermis 1 cm in width was excised. A full-thickness wedge of the epidermis, dermis, subcutaneous fat, and flap was excised inferior to the nipple to reduce the width of the inferior pole of the reconstructed breast (Figures 3,4).

Figure 3 The periareolar epidermis was scored in two concentric rings and a ring of epidermis of 1 cm width was excised. A full thickness wedge of epidermis, dermis, subcutaneous fat and flap was excised inferior to the nipple to reduce the width of the inferior pole of the reconstructed breast.

Figure 4 The nipple areolar complex was elevated on a reinforced pedicle of mastectomy dermis and subcutaneous fat in combination with the underlying flap dermis and subcutaneous fat. The total height of the reinforced pedicle was 1 cm. Only the inferior half of mastectomy dermis surrounding the nipple areolar complex was incised and undermined, with the superior half left intact.

The NAC was elevated on a reinforced pedicle of the mastectomy dermis and subcutaneous fat in combination with the underlying flap dermis and subcutaneous fat (Figure 4). The total height of the reinforced pedicle was 1 cm. The pedicle was completely elevated on the undersurface and through the inferior half of its dermal attachment. Thus, the NAC in the reinforced pedicle has a dual blood supply (Figure 5). The first through its dermal attachments superiorly to the mastectomy skin, which is supplied via the subdermal plexus and subcutaneous vessels that are extensions of the intercostal perforators (6). The second is through the free flap’s blood supply, which is independent of the mastectomy dermis, and which may or may not still be reliant on its pedicle (7,8).

Figure 5 Diagram demonstrating the reinforced pedicle technique of NAC elevation. The NAC is elevated on a four-layer pedicle of mastectomy dermis, mastectomy subcutaneous fat, free flap dermis and free flap subcutaneous fat. The pedicle has a dual or “hybrid” blood supply; first, via the superior blood supply to the mastectomy dermis, and second via a random pattern blood supply to the elevated portion of the free flap. NAC, nipple areolar complex.

Postoperatively, the native NAC was safely raised by 2.5 cm. Surgery was performed as a day procedure. No wound healing issues were encountered with the new incisions, and the NAC remained healthily perfused throughout. At 3 months post-operative, a slight asymmetry between the NAC positions of the two breasts persisted. However, the patient was pleased with her results and declined further revision surgery (Figure 6).

Figure 6 The patient is shown 3 months post reinforced pedicle revision. The symmetry of her reconstructed breasts and the levels of her native nipple areolar complexes are significantly improved compared to Figure 2. The reinforced pedicle method uniquely enables us to excise excess flap volume from the inferior pole, which we find is the most effective method of reducing ptosis in the reconstructed breast.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

There is a paucity of literature on free flap revisions and symmetrizing procedures in breast reconstruction, especially in the setting of the ptotic reconstructed breast post-NSM. Even without significant ptosis, the rate of NAC repositioning after NSM is estimated at 7.4%, with autologous reconstruction and preoperative radiation therapy as a positive independent predictors (9). The few techniques described specifically for the ptotic breast include both one- and two-stage approaches and are summarized in Table 1. In the single-stage approach, NSM, autologous breast reconstruction, and mastopexy are performed during a single surgery. Varnava et al. described a single-stage approach, in which the blood supply to the NAC was preserved on an inferior dermal pedicle. The pedicle had a retroareolar thickness of 0.5 and 1 cm for the remainder of the pedicle. They performed this on five patients (10 free flaps) and had a partial NAC necrosis rate of 30% (10). Samaras and Malata published a case series of 13 NSM and immediate reconstructions in seven patients. Reconstruction methods include DIEP and superficial inferior epigastric artery (SIEA) free flaps as well as pedicled latissimus dorsi reconstructions with and without implants. In one patient, they undertook NSM with simultaneous vertical pattern mastopexy and immediate free flap reconstruction. This patient experienced bilateral NAC necrosis, leading them to conclude “a staged approach to the nipple preservation with a prior mastopexy, for instance, would be a safer strategy” (4).

DellaCroce et al. advocated a two-stage approach involving NSM and immediate autologous reconstruction in the first stage. Three to six months later, the patients underwent a modified mastopexy to lift the NAC. Their technique involves either a Wise pattern or vertical lift skin incision, depending on the degree of ptosis, followed by a flap reduction technique akin to the inferior pedicle mammoplasty. They elevate the superior mastectomy skin off the reconstructed breast and reduce its superior, medial and lateral poles as required. The skin is then re-draped around the NAC, which survives based on the blood supply of the underlying flap. Significantly, the reconstructed breast remains adherent to the chest wall across the entire base of the neo-breast plate. Through this technique, DellaCroce et al. have proven that, if delayed, the NAC can survive based on the blood supply from the underlying flap completely severed from its mastectomy skin attachments. In their series of 116 flaps, there were no instances of NAC necrosis, even in women with mastectomy weights up to 877 grams (11).

The main advantage of the reinforced pedicle technique over DellaCroce et al.’s technique is the increased mobility of the NAC based on the superior pedicle of the mastectomy skin dermis and the underlying flap. The DellaCroce et al. technique is similar to the inferior pedicle breast reduction technique, whereas the reinforced pedicle is more analogous to vertical pedicle breast reduction (11,14). As such, it allows for a greater elevation of the NAC, less bottoming out, and greater fullness of the superior pole. Additionally, the technique of DellaCroce et al. relies on the mastectomy skin to act as a brassiere to lift the reconstructed breast, while the reinforced pedicle allows for reshaping of the breast (11).

In their approach to the revising the reconstructed breast, Zafar and Ellsworth utilize a Wise pattern or circumvertical skin excision pattern. However, their exact technique of reduction or shaping of the flap and the orientation of the preserved pedicle has not been described (12). Schneider et al. also published a retrospective chart review of immediate autologous reconstruction after NSM in patients with grade 2 or 3 ptosis. They analyzed 85 patients who underwent 141 free flaps. Five (26%) patients underwent mastopexy or breast reduction as a secondary procedure but their exact technique and rates of subsequent NAC compromise are not described (13).

Conclusions

The reinforced pedicle is a novel and safe method for secondary breast reduction and elevation of the native NAC in autologous reconstructed breasts. However, while this paper outlines the theory and surgical technique behind the reinforced pedicle, further studies, such as a case series, are needed to better evaluate the safety and limitations of this technique.

In addition, further studies into whether it is feasible to perform NSM, NAC elevation and autologous reconstruction as a single stage are warranted. This has been demonstrated in implant-based reconstruction with rates of skin necrosis of 10% and minor NAC necrosis of 5%, but never in autologous reconstruction (15). Wise pattern SSM at the same time as free flap reconstruction has been studied, with a reported complication rate of 30% (16). However, to our knowledge, wise pattern NSM with immediate free flap reconstruction has been reported only twice in the literature, by Varnava et al. and by Samaras and Malata, both with high complication rates (4,10).

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-24-109/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-109/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-109/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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