What the what?
This was an article in November 2019 Plastic & Reconstructive Surgery Journal. “Does Staged Breast Reduction before nipple Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques.”
This is actually a really great study to look at. Mastectomies are where you remove the breast because of breast cancer or prophylactically because you have a strong genetic risk of cancer. Nipple sparing mastectomies are awesome. Nothing looks like a nipple and areola like your actual nipple and areola. If we can do a mastectomy and safely keep this area, your breast reconstruction looks so much better. The issue is sometimes the nipple and skin can die because of blood supply issues. In a droopy breast (do you pass the pencil test?), you need to do a lift at the same time, which puts that nipple area at even HIGHER risk.
So the thought is to stage the reconstruction. When you do this, you do a breast reduction first. Let that heal. The body forms a new blood supply to the skin and nipple area. Then you do a nipple sparing mastectomy.
So does it work?
Study:
Retrospective review of patients that had staged breast reduction 5 months before their nipple sparing mastectomy. They then paired these against nonstaged (had the lift at the same time as mastectomy). 18 breasts in total were identified. They were matched with 36 nonstaged. They usually used a medial/superomedial pedicle for blood supply during the reduction (the same technique I use.) No patients had a history of diabetes, smoking, or neoadjuvant therapies.
- Average weight of tissue removed was higher in the staged group. 994 vs 640 grams. (At the reduction, on average 383 grams were removed).
- Major flap necrosis rates (where skin dies) was significantly lower in the staged group (0% s 22%)
- Rates of minor flap necrosis, partial nipple loss and explantation (where the implant needed for reconstruction is removed) is lower in the staged surgery.
- CONCLUSION: In patients with large breast size, staged breast reduction before nipple sparing mastectomy had significantly lower rates of major flap necrosis.
My thoughts?
Good study. It totally makes sense, and if you have a low risk tumor (small, slow growing) or are doing the mastectomy prophylactically (because of BRCA or other), I think this is an ideal surgery. My only thought was that you have to stage this, so you have to wait between surgeries. How long? In their study the average time between surgeries was 5 months (it ranged 3-6 months). In their study, the reductions were the Wise pattern (anchor scar). I do not use this scar for my reductions. I would be curious to see if there is any difference in type of reduction.