Nipple delay prior to nipple-sparing mastectomy: the protective effect on nipple-areola complex ischaemia.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become increasingly popular over the past decade, offering perceived superior cosmetic outcomes and psychological benefits. The main concern in NSM is that of nipple-areola complex (NAC) ischaemia, occurring in up to 15% of cases. We investigate the utility of nipple delay (ND) in protecting the NAC from ischaemic complications. METHODS: A retrospective study of all NSM for a single surgeon from 2010 to 2020 was performed, with those not receiving a prior ND procedure included as a control arm. Variables were recorded, including time to mastectomy from delay, degree of breast ptosis, cup size, mastectomy weight, previous radiotherapy, and presence of ischaemic risk factors. Outcomes recorded were the development of NAC ischaemia, graded from epidermolysis to partial or full-thickness necrosis (FTN). RESULTS: A total of 62 women for a total of 84 breasts were part of the delay cohort. Ten (12%) breasts in the delay group developed ischaemic complications, with only five breasts developing FTN requiring debridement. Moreover, 33 women for a total of 43 breasts were part of the non-delay cohort. A total of 14 (33%) breasts in the non-delay cohort developed ischaemic complications, with six breasts developing FTN requiring debridement. Delay was protective against ischaemic complications with an OR 0.28 (p=0.007). Mastectomy weight of >600 g and >400 g predicted the development of ischaemic complications in the delay and non-delay cohorts, respectively. CONCLUSION: ND was shown to protect against the development of ischaemic complications prior to NSM, with the greatest protective effects shown in those with morphologically large breasts.

The Deep Inferior Epigastric Perforator Learning Curve in the Current Era.

BACKGROUND: Over the last 2 decades, the deep inferior epigastric perforator (DIEP) flap has gained significant popularity in breast reconstruction. However, for some, the increased technical difficulties associated with DIEP breast reconstruction can be a discouraging factor in adopting this technique. There has been a trend in the literature to acknowledge an acute learning curve in the adoption of DIEP breast reconstruction but little evidence to support its ongoing relevance to surgeons who gain significant exposure in training. METHODS: We test the learning curve concept on the senior author's series of 214 DIEP and superficial inferior epigastric artery flaps in a single-surgeon, retrospective study analyzing chronological trends in complication rates both major (total and partial flap loss, reexploration) and minor (fat necrosis, donor site hernia and bulge). RESULTS: The total complication rate was 7.9%, including 1 (0.5%) partial and 1 (0.5%) total flap failure. A comparison of complication rates in the initial 30 flaps in comparison to the remainder of the series revealed no significant difference in major complications (3.3% vs 3.3%, P = 1.00) or minor complications (6.7% vs 4.3%, P = 0.635). Linear-by-linear analysis performed on chronologically ordered groups of 30 flaps revealed no statistically significant trends over the series. CONCLUSIONS: The learning curve associated with the DIEP is complex and likely relates to competency gained in both technical and decision-making aspects of breast reconstruction. This series has demonstrated that with adequate training and an algorithmic approach to DIEP breast reconstruction, eliminating the early learning curve and improving early outcomes are possible.

The inferior gluteal artery myocutaneous flap with vascularized fascia lata to reconstruct extended abdominoperineal defects.

UNLABELLED: Abdominoperineal resections have evolved to the point where increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation. The authors have developed a novel innervated gluteal flap reconstruction with significant advantages, including preservation of abdominal wall integrity, prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance of perineal floor integrity, and importation of nonirradiated skin to facilitate primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.