From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health.
Plast Reconstr Surg. 2019 Nov;144(5):1023-1032. doi: 10.1097/PRS.0000000000006121.
Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking.
A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes.
Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort.
In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
对于乳房较大且下垂的患者，行保留乳头的乳房切除术是一种具有挑战性的重建方法。研究表明，行分期乳房缩小术可减少预防性保留乳头的乳房切除术的并发症；然而，缺乏分期与非分期技术之间结局的直接比较。
对所有行分期乳房缩小术以行保留乳头的乳房切除术的患者进行回顾性研究。分期病例根据已知的并发症危险因素与非分期保留乳头的乳房切除术病例相匹配。在所有这些类别中具有适当匹配的各个分期病例，然后根据最近的较高和较低乳房切除术重量与两个非分期病例相匹配。比较分期和非分期队列的人口统计学、手术特征和重建结局。
共确定了 18 例分期乳房缩小术，平均在保留乳头的乳房切除术前 5.0 个月进行。分期缩小术与 36 例预防性非分期缩小术相匹配。分期组的平均联合乳房切除术重量（乳房缩小术和乳房切除术的总重量）明显高于非分期组（992.6g 比 640g；p = 0.0004），尽管单纯乳房切除术的重量相当（分别为 607.1g 和 640.0g；p = 0.6311）。分期组的主要乳房皮瓣坏死率明显低于非分期组（分别为 0%和 22.2%；p = 0.0415）。分期组的小面积乳房皮瓣坏死、部分乳头坏死和假体取出率也呈下降趋势。
在乳房较大的患者中，与非分期病例相比，在控制其他已知并发症危险因素后，行保留乳头的乳房切除术前行分期乳房缩小术可显著降低主要皮瓣坏死的发生率。
临床问题/证据水平：治疗性，III 级。
