Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: a comparison between the Wise and Vertical reduction patterns for mastectomy
Ines C. Lin, MD, Joseph M. Serletti, MD, Liza C. Wu, MD.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
PURPOSE: Management of the ptotic or hypertrophic breast in immediate breast reconstruction following mastectomy often requires skin-reducing procedures. A reduction pattern can be applied to the mastectomy as a technique to address the excessive skin, but limitations include a relatively high rate of mastectomy flap necrosis and a flattened breast shape. This study is a critical evaluation of the Wise and vertical reduction patterns for mastectomy in immediate autologous breast reconstruction.
METHODS: Two cohorts of patients were prospectively collected. 26 consecutive, immediate autologous breast reconstructions in 17 patients with ptotic or hypertrophic breasts were performed utilizing the Wise pattern for skin sparing mastectomies. 28 consecutive, immediate autologous breast reconstructions in 16 patients were performed with the vertical reduction pattern. The patients did not differ significantly in age, comorbidities, BMI, breast size, or nipple-to-notch and nipple-to-inframammary fold distances. All reconstructions were performed by one plastic surgeon, and the mastectomies were done by an oncologic surgeon. The patients were followed for complications, wound healing difficulties, and patient satisfaction at 6 and 12 months after surgery.
RESULTS: For the Wise pattern mastectomy incisions, 19 of the 26 reconstructions had a significant amount of mastectomy flap necrosis with the average area of 56.6 cm2. Seven patients required at least 4 weeks of local wound care or skin grafting; three patients required a second trip to the operating room for skin grafting. Only 7 of the 26 breast reconstructions with the Wise pattern incision experienced minimal mastectomy skin loss (0-2 cm2). In comparison, for the vertical pattern mastectomy incisions, 16 reconstructions had no mastectomy skin loss. The remaining 12 flaps had an average area of mastectomy flap skin loss of 8.8 cm2 that were managed conservatively with no patients needing skin grafting, a significantly lower average compared to the Wise pattern incision (p<0.01).
CONCLUSIONS: Little has been published about the vertical reduction pattern for mastectomy in the hypertrophic or ptotic breast, and to date, there is no comparison between the Wise and vertical reduction patterns for mastectomy in immediate autologous breast reconstruction. The Wise pattern incision for skin sparing mastectomy is associated with a high rate of partial mastectomy flap loss requiring weeks of local wound care or skin grafting. In contrast, the vertical reduction pattern results in significantly lower rate of mastectomy flap necrosis and revisions. The vertical pattern is feasible in all patients and results in an aesthetically pleasing shape. In conclusion, we strongly recommend the vertical reduction incision for skin-sparing mastectomy in the ptotic or hypertrophic breast and immediate autologous breast reconstruction.