Immediate breast reconstruction following nipple-sparing mastectomy in an Asian population: Aesthetic outcomes and mitigating nipple-areolar complex necrosis

BACKGROUND: Nipple-sparing mastectomies (NSMs) are increasingly performed to obtain the best aesthetic and psychological outcomes in breast cancer treatment. However, merely preserving the nipple-areolar complex (NAC) does not guarantee a good outcome. Darkly pigmented NACs and a tendency for poor scarring outcomes are particular challenges when treating Asian patients. Herein, we review the reconstructive outcomes following NSM at Singapore General Hospital. METHODS: All breasts reconstructed following NSM over an 11-year period from 2005 to 2015 were reviewed. Information was collected from the patients' records on mastectomy indications, operative details, and complications. Patient satisfaction, breast sensation, and aesthetic outcomes were evaluated in 15 patients. Sensation was quantified using the Semmes-Weinstein monofilament test. RESULTS: A total of 142 NSMs were performed in 133 patients for breast cancer (n=122, 85.9%) or risk reduction (n=20, 14.1%). Of the procedures, 114 (80.2%) were autologous reconstructions, while 27 (19.0%) were reconstructions with implants. Complications occurred in 28 breasts (19.7%), with the most common complication being NAC necrosis, which occurred in 17 breasts (12.0%). Four breasts (2.8%) had total NAC necrosis. The overall mean patient satisfaction score was 3.0 (good). The sensation scores were significantly diminished in the skin envelope, areola, and nipple of breasts that had undergone NSM compared to non-operated breasts (P < 0.05). Half of the subset of 15 patients in whom aesthetic outcomes were evaluated had reduced nipple projection. CONCLUSIONS: Immediate reconstruction after NSM was performed with a low complication rate in this series, predominantly through autologous reconstruction. Patients should be informed of potential drawbacks, including NAC necrosis, reduced nipple projection, and diminished sensation.

Use of the Anterolateral Thigh and Vertical Rectus Abdominis Musculocutaneous Flaps as Utility Flaps in Reconstructing Large Groin Defects

BACKGROUND: Groin dissections result in large wounds with exposed femoral vessels requiring soft tissue coverage, and the reconstructive options are diverse. In this study we reviewed our experience with the use of the pedicled anterolateral thigh and vertical rectus abdominis musculocutaneous flaps in the reconstruction of large groin wounds. METHODS: Groin reconstructions performed over a period of 10 years were evaluated, with a mean follow up of two years. We included all cases with large or complex (involving perineum) defects, which were reconstructed with the pedicled anterolateral thigh musculocutaneous or the vertical rectus abdominis musculocutaneous (VRAM) flaps. Smaller wounds which were covered with skin grafts, locally based flaps and pedicled muscle flaps were excluded. RESULTS: Twenty-three reconstructions were performed for large or complex groin defects, utilising the anterolateral thigh (n=10) and the vertical rectus abdominis (n=13) pedicled musculocutaneous flaps. Femoral vein reconstruction with a prosthetic graft was required in one patient, and a combination flap (VRAM and gracilis muscle flap) was performed in another. Satisfactory coverage was achieved in all cases without major complications. No free flaps were used in our series. CONCLUSIONS: The anterolateral thigh and vertical rectus abdominis pedicled musculocutaneous flaps yielded consistent results with little morbidity in the reconstruction of large and complex groin defects. A combination of flaps can be used in cases requiring extensive cover.