Management of the ptotic or hypertrophic breast in immediate autologous breast reconstruction: an evaluation of the Wise pattern mastectomy incision.
Ines C. Lin, MD, Joseph M. Serletti, MD, Liza C. Wu, MD.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Background: Management of the ptotic or hypertrophic breast in immediate breast reconstruction following mastectomy often requires skin-reducing procedures. The Wise reduction pattern can be applied to the mastectomy as a technique to address the excessive skin. However, this approach is limited by the relatively high rate of mastectomy flap necrosis. This study is a critical evaluation of the Wise pattern mastectomy incision in immediate autologous breast reconstruction.
Methods: 26 immediate autologous breast reconstructions in 17 patients with ptotic or hypertrophic breasts were consecutively done utilizing the Wise pattern for skin sparing mastectomies between May 2007 and April 2008. The incisions were designed by the plastic surgeon, and the mastectomies were done by the oncologic surgeon. The patients were followed post-operatively for surgical complications, wound healing difficulties, breast aesthetics, and patient satisfaction.
Results: Of the 17 patients, 9 had bilateral breast reconstructions while 8 had unilateral breast reconstructions. The average patient age was 50.9 years. The average sternal notch-to-nipple distance was 30.75 cm (range 22.5-38 cm), and the average nipple-to-inframammary fold (IMF) distance was 13.4 cm (9-20 cm range). Average mastectomy specimen weight was 1304 g (295-2600 g). Only 7 of the 26 breast reconstructions (in 5 patients) experienced negligible mastectomy skin loss (0-2 cm2). Half of the reconstructions had more than 30 cm2 of skin loss with an average area of mastectomy flap necrosis of 56.6 cm2. 3 patients required a second trip to the operating room for skin grafting. All other wounds were managed with silvadene or wet-to-dry dressings. When comparing the patients that had minimal mastectomy flap necrosis to those with larger areas of mastectomy flap necrosis, there was no statistically significant difference in sternal notch-to-nipple distance, nipple-to-IMF distance, mastectomy specimen weight, or patient age. Patients with partial mastectomy flap skin loss had a statistically significant higher body-mass index (BMI) than patients with minimal flap necrosis (average BMI’s of 33.4 and 27.3, respectively; p=0.02). All patients were either non-smokers or had quit smoking at least 3 months prior to surgery. For the unilateral patients, 6 of 8 had a contralateral balancing procedure at time of mastectomy and reconstruction. In regards to the reconstruction, there were no flap losses.
Conclusions: In our experience, using the Wise pattern incision for skin sparing mastectomy in the ptotic or hypertrophic breast is associated with a high rate (70%) of partial mastectomy flap loss requiring weeks of local wound care or skin grafting. Obese patients, with a BMI greater than 33, are at significantly higher risk for mastectomy flap necrosis. These results suggest the need to investigate other mastectomy incisions for the ptotic breast to address both cosmesis and optimal wound healing.