Approaches to microvascular breast reconstruction after total skin-sparing mastectomy: a comparison of techniques

Preserving the entire breast skin envelope through total skin-sparing mastectomy (TSSM) techniques, in conjunction with immediate autologous reconstruction, can provide excellent aesthetic outcomes for patients. However, postoperative ischemic complications, including nipple-areolar complex (NAC) and skin flap necrosis, can negatively impact reconstructive outcomes. As a strategy for minimizing ischemic complications, we have recently begun performing 2-stage autologous reconstruction after TSSM with immediate tissue expander placement, followed by second-stage microvascular reconstruction, as an alternative to immediate autologous reconstruction.

A prospectively collected database of patients undergoing TSSM and immediate breast reconstruction was reviewed for patients who underwent microvascular reconstruction. Patients were divided into 2 cohorts, those who underwent immediate microvascular reconstruction and those who had a 2-stage procedure. Outcomes for comparison included complication rates and aesthetic outcome scores based on review of postoperative photographs by blinded observers (comprised of plastic surgery attending physicians and residents).

During the 2-year study period, there were 21 immediate microvascular reconstructions performed (14 patients) and 16 two-stage reconstructions performed (10 patients). Mean time to completion of reconstruction in the staged cohort was 11.5 months (range, 6.1-21 months). Rates of NAC necrosis were significantly higher in the immediate cohort compared to the staged cohort (29% vs 0%, P=0.03), which contributed to higher rates of unplanned operative intervention in the immediate cohort (23.8% vs 6.25%, P=0.14). There were no flap losses in either cohort. Aesthetic scores for NAC color and overall appearance were higher in the staged group compared to the immediate group (P<0.001 and P=0.1, respectively), although they were equivalent for nipple position and projection.

Two-stage microvascular reconstruction after TSSM is associated with fewer complications and improved NAC aesthetic outcomes compared to immediate autologous reconstruction. Although time to final reconstruction is longer with the staged approach, the aesthetic benefits and reduction in postoperative complications support the use of this approach to optimize outcomes.