Moving Towards Optimizing Outcomes in Nipple-Sparing Mastectomy: Mastectomy Flap Thickness is Not One Size Fits All
Jordan D. Frey, M.D., Ara A. Salibian, M.D., Mihye Choi, M.D., Nolan S. Karp, M.D..
NYU Langone Health, New York, NY, USA.
Nipple-sparing mastectomy (NSM) places greater stress on the breast-skin envelope compared to traditional mastectomy techniques. Precise mastectomy flap dissection is critical to optimize breast skin flap thickness and minimize risks of reconstructive complications. This study evaluated patient-specific factors associated with mastectomy flap quality to improve technical success in NSM.
NSM flap thickness was determined for all NSMs from 2006 to 2016 with available pre-operative breast MRIs. Demographic, operative variables, and flap thickness were compared for NSMs as stratified by body-mass index (BMI) and mastectomy weight.
Of 1037 NSM reconstructions, 420 cases (40.5%; 243 patients) had MRI data available, which included 379 (36.5%) preoperative breast MRIs. Average BMI was 24.08 kg/m2 while average mastectomy weight was 442.28 grams.
Average overall NSM flap thicknesses per BMI subcategories were 10.43 in patients with BMI <25 kg/m2, 12.54 in BMIs of 25-30 kg/m2, and 14.91 millimeters in BMIs and >30 kg/m2. Each incremental increase in average overall NSM flap thickness per BMI category was statistically significant (p<0.0001; p<0.0001; p=0.0002). The R2 correlation value of flap thickness with increasing BMI was 0.26. Each category increase in BMI was also associated with a significant increase in NSM flap thickness in the anterior, middle, and posterior breast dimensions.
Average overall NSM flap thicknesses in NSMs classified by mastectomy weight categories were 9.97 for weight <400 grams, 12.21 for 400-799 grams, and 14.50 millimeters for ≥800 grams. Again, each incremental increase in average overall NSM flap thickness per mastectomy weight category was statistically significant (p<0.0001; p<0.0001; p<0.0001). The R2 correlation value of flap thickness with increasing BMI was 0.23. Each category increase in mastectomy weight was also associated with a significant increase in NSM flap thickness in the anterior, middle, and posterior breast dimensions.
NSM flap thickness and quality is related to body-mass index and breast size. Characterizing these anatomic variations preoperatively will help surgeons optimize mastectomy flaps dissections and minimize ischemic complications in breast reconstruction after NSM.
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