The delayed preshaped-breast principle after nipple-sparing mastectomy

Ondertitel:a safe two-staged breast reconstruction in the anatomically challenging breast

This thesis is about the anatomical and surgical feasibility of nipple-sparing mastectomy (NSM) in anatomical high-risk patients, women with large and ptotic breasts. NSM in large breasts with important ptosis is still considered a contraindication because of the increased risk of NAC necrosis. Chapter 1 provides an overview of the types of breast reconstruction (BRC) that are performed after mastectomy. BRC aims to improve quality of life by recreating a natural-looking breast. Ideally when breast’s footprint and skin envelope are preserved, the only remaining reconstruction is the conus. This is exactly how NSM is thought of in general: replace the glandular volume by another volume while skin envelope, nipple and footprint remain undisturbed. Skin envelope and nipple will cover the new conus. Chapter 2 reports on different techniques and one-or-two-stage approach as well as the overall outcome of these techniques. Chapter 2 shows a tendence of less necrosis in a staged NSM approach. A two-staged approach with a robust direct perforator-perfused pedicle in Chapter 3 is the best strategy to prevent NAC and skin necrosis in the large and/or ptotic breast. Wise pattern skin envelope reduction has the advantage of skin envelope delay. In the best of both worlds, a robust perforator-perfused pedicle delays NAC at its distal end. The same reduction pattern also delays and reduces the skin envelope. Retropectoral expander to prosthesis placement creates a capsule that will support and protect the definite prosthesis. The circumareolar full thickness scars around NAC will be reliable enough to reperfuse the nipple on a completely dermal basis. The results of Spear, Alperovich, Schwartz and Gunnarson et al (29,30,32) support this reliability. Chapter 4 shows the clinical reliabity and focusses on the immediate necrotic outcomes as well as on the pitfalls of this approach. To fully understand this technique, the reader needs to understand the dynamic vascular anatomy behind it. Chapter 5 shows the preliminary results in six breasts of the effect of delay on NAC perfusion patterns in a real-time dynamic manner with the use of near-infrared indocyanine-green fluorescence videography. Chapter 6 prospectively mimics our two-stage delayed approach in a porcine model and consists of two parts. In part A we perform our technique in six Aachener mini-pigs. We describe our clinical approach and report absence of necrotic outcome. We also show the shift to strictly dermal NAC perfusion in a real-time dynamic manner with the use of near-infrared indocyanine-green fluorescence videography. Part B shows the time-dependency of NAC delay in twelve Aachener pigs: NAC delay in two-stages is safe within four weeks. No necrosis is shown. In the general discussion we do not only focus on the interpretations of the results obtained in the previous chapters, but also discuss the underlying functional anatomy. Future breast reconstruction as well as other surgical possibilities arise based on the obtained dynamic anatomical insights.

Jaar van publicatie:2022

Trefwoorden:Doctoral thesis

Toegankelijkheid:Open