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Year : 2021  |  Volume : 29  |  Issue : 5  |  Page : 9-13

Predicting mastectomy skin flap necrosis in immediate breast reconstruction

1 Department of Plastic, Reconstructive and Aesthetic Surgery, Marmara University School of Medicine, Istanbul, Turkey
2 Department of General Surgery, Marmara University School of Medicine, Istanbul, Turkey

Date of Submission18-Nov-2020
Date of Acceptance04-Jan-2021
Date of Web Publication17-Mar-2021

Correspondence Address:
Dr. Zeynep Akdeniz Dogan
Department of Plastic Reconstructive and Aesthetic Surgery Marmara University School of Medicine, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_117_20

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Background: As evidence emerged supporting the oncological safety of nipple-sparing mastectomy (NSM), immediate reconstruction following these procedures has also gained popularity. The aim of this study was to identify surgical and patient characteristics that may be associated with skin and/or NAC necrosis following NSM and immediate reconstruction. Patients and Methods: Medical records of patients who underwent NSM with immediate breast reconstruction from January 2013 to September 2020 were retrospectively reviewed. Patient and surgical characteristics were collected. The primary outcome measure was mastectomy skin flap necrosis (MSFN). Results: MSFN was observed in 68 out of 243 (28%) breasts. On univariate analysis, reconstruction method and body mass index (BMI) (odds ratio: 1.09, 95% confidence interval: 1.00–1.18, P = 0.04) were found to be significant risk factors. On multivariate analysis, neither BMI (P = 0.30) nor reconstruction methods (implants (P = 0.16) or tissue expander (P = 0.06) showed significant association with skin flap necrosis. However, BMI was found to be significantly higher in the autologous group (P < 0.0001). The best subset selection method also confirmed the reconstruction method as the single variable related to outcome. Conclusion: Even though our results showed autologous reconstruction to have a higher risk for necrotic complications, it should be kept in mind that this group of patients can be managed in the outpatient clinic with debridement, wound care, and – if necessary – skin grafting. However, full-thickness necrosis in an implant patient will require an implant exchange and possibly a local skin/muscle flap for coverage.

Keywords: Breast reconstruction, mastectomy skin flap necrosis, nipple-sparing mastectomy

How to cite this article:
Dogan ZA, Onal M, Ozkan MC, Ugurlu U, Sacak B. Predicting mastectomy skin flap necrosis in immediate breast reconstruction. Turk J Plast Surg 2021;29, Suppl S1:9-13

How to cite this URL:
Dogan ZA, Onal M, Ozkan MC, Ugurlu U, Sacak B. Predicting mastectomy skin flap necrosis in immediate breast reconstruction. Turk J Plast Surg [serial online] 2021 [cited 2022 Jun 29];29, Suppl S1:9-13. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/9/311428

  Introduction Top

As evidence emerged supporting the oncological safety of skin-sparing and nipple-sparing mastectomy (NSM),[1],[2],[3],[4] immediate reconstruction following these procedures has also gained popularity. Since these procedures are opted to improve cosmesis and patient satisfaction,[2],[5],[6] maintaining well-vascularized skin flaps and nipple-areola complex (NAC) is of crucial importance. Several studies have identified weight of breast resection (WBR), periareolar incision, prior radiotherapy, reconstruction with implants, NSM, smoking history, diabetes mellitus, and body mass index (BMI)[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] as potential risk factors associated with NAC and/or mastectomy skin flap necrosis (MSFN).

Improvements in esthetic outcomes have also increased patients' expectations.[18],[19] Therefore, it is important to describe the predictors of MSFN to provide better consultation to our patients and avoid failed reconstructions. The aim of this study was to analyze our surgical and patient characteristics that may be associated with skin and/or NAC necrosis following NSM and immediate reconstruction.

  Patients and Methods Top

Study design

Medical records of patients who underwent NSM with immediate breast reconstruction from January 2013 to September 2020 in our facility were retrospectively reviewed. Patient characteristics such as age, BMI, comorbidities (diabetes mellitus, peripheral vascular disease, history of deep vein thrombosis, or emboli), smoking history, history of neoadjuvant chemotherapy, preoperative radiotherapy, and prior breast surgery were recorded. Surgical characteristics such as incision site, reconstruction method, implant volume, and perioperative tissue expander volume were also noted.

Surgical techniques

All mastectomies were performed by a single general surgeon using electrocautery. NSMs were performed through three types of incisions: inframammary fold (IMF), lateral, and vertical. A lateral incision was defined as a superior or inferior periareolar incision extending laterally. A vertical incision was defined as an incision starting from the lower edge of the NAC extending down to the IMF. The site of mastectomy incision was mutually agreed on the following discussion with the general surgeon. Factors such as breast size and tumor location were taken into consideration. In the earlier periods of our practice, the lateral incision was preferred for patients with small-to-moderate size breasts. Later, for this group of patients, IMF incision was performed. A vertical incision was preferred for relatively larger breasts. The reconstructive methods performed included autologous tissue (deep inferior epigastric artery perforator flap [DIEP], superficial inferior epigastric artery flap [SIEA], transverse rectus abdominis muscle flap [TRAM], and transverse upper gracilis flap), direct to implant [DTI] or tissue expander. Implants were either placed in total submuscular/subfascial plane or dual plane with lower pole covering provided by acellular dermal matrix. Tissue expanders were inflated with saline solution less than the maximum amount and placed under the pectoralis muscle superiorly and the lower poles were covered with serratus muscle fascia.

Outcome measures

The primary outcome measure was MSFN which was defined as any partial or full-thickness skin and/or NAC necrosis that required wound care or debridement in outpatient or inpatient settings.

Statistical analysis

The data were analyzed using Python H2O Chi-square or analysis of variance was used to compare patient characteristics. Potential risk factors for MSFN were examined using a univariate logistic regression model. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were calculated. Multivariate logistic regression analysis was conducted using the best subset selection algorithm. Using Akaike Information Criterion, the most parsimonious model was selected. P value below 0.05 was considered statistically significant.

  Results Top

A total of 180 patients underwent NSM with immediate reconstruction for 243 breasts. Sixty-three patients (35%) had bilateral mastectomy. The mean age for all patients was 44.7 ± 8.6 years and the mean BMI was 25.6 ± 4.0 kg/m2. About 33.3% of patients had history of smoking and 10.7% of patients had comorbidities. All mastectomies were performed by a single general surgeon using electrocautery. Three different incisions were mainly used; IMF (42.4%), lateral (25.9%), and vertical (26.7%). No record of incision type could be found on 12 breasts on a retrospective review of the data. Immediate reconstructions were performed by the plastic surgery team where reconstruction with autologous tissue was performed on 42.4% of patients. Out of 104 patients who received autologous reconstruction, 93 patients had DIEP flap, 7 patients had TRAM flap, 2 patients had SIEA flap, and 1 patient had transverse upper gracilis flap. Four patients with TRAM flap, 1 patient with gracilis flap, and 33 patients with DIEP flap had necrotic complications. DTI reconstruction was performed on 42.8%, whereas 14.8% of patients received a tissue expander. Patient and surgical characteristics are summarized in [Table 1].
Table 1: Patient characteristics

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MSFN was observed in 68 out of 243 (28%) breasts. On univariate analysis, reconstruction method and BMI (OR: 1.09, 95% CI: 1.00–1.18, P = 0.04) were significant risk factors for NAC and/or skin flap necrosis [Table 2]. Compared to reconstruction with autologous tissue, reconstruction with implants was found to decrease the risk of necrosis by 0.51 fold (95% CI: 0.28–0.94, P = 0.03) and tissue expander placement decreased the risk by 0.34 fold (CI 95%: 0.13–0.90, P = 0.02). The best subset selection algorithm also confirmed univariate regression analysis that the reconstructive method was the best model that explains the data. When patient characteristics were analyzed according to the reconstruction method, BMI (P < 0.0001), comorbidities (P = 0.001), and history of neoadjuvant chemotherapy (P = 0.05) were significantly higher in the autologous group compared to implant and tissue expander groups [Table 3]. In order to control confounders, multivariate logistic regression analysis was performed, which showed neither BMI (P = 0.30) nor reconstruction methods (implants (OR: 0.61 CI 95%: 0.30–1.21, P = 0.16) or tissue expander (OR: 0.38 CI 95%: 0.96–1.15, P = 0.06)) were associated with skin flap necrosis.
Table 2: Univariate statistical analysis

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Table 3: Characteristics among reconstruction methods

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  Discussion Top

We have analyzed possible risk factors for skin flap and/or NAC necrosis following NSM and immediate reconstruction. Our results showed 28% overall necrosis, including partial and full-thickness necrosis. Rates of NAC necrosis range between 0% and 48% in the literature,[2],[8],[12],[14],[20],[21] but a recent meta-analysis has revealed relatively low rates of complete (2.49%) and partial (4.62%) NAC necrosis.[22] Our report includes all partial and full-thickness necrotic complications of the skin and NAC which may explain the relatively higher rate of necrosis in our series.

Our analysis revealed that only the reconstruction method was significantly associated with MSFN. The choice of placing a tissue expander mostly depended on whether the patient had planned postmastectomy radiation therapy (PMRT) or not. For most patients who require PMRT, we would offer expander placement, especially in the earlier stages of our practice. Another reason for placing an expander was the recent COVID-19 pandemic that started in January 2020. The patients were offered staged reconstruction to ensure shorter stays in the hospital, in compliance with the guidelines of the National Society of Plastic Surgeons.[23] The choice of reconstruction (autologous vs. implant) mainly depended on patients' preferences and body type. Patients with delayed-immediate reconstruction, where tissue expanders were placed following mastectomies, had significantly less necrotic complications. This is a reasonable finding, given that the tissue expanders are not filled up to maximum capacity during the operation, resulting in less tension on the mastectomy skin flaps. Garwood et al., earlier in their practice, have implemented more DTI and observed necrotic complications and implant loss.[14] This has encouraged them to transition to placing TE with minimal expansion in the immediate setting resulting in significantly improved outcomes. Perioperative expander volume was not associated with skin flap necrosis in our series. Tissue expanders were inflated with varying volumes preoperatively without placing too much tension on the skin flaps. Our data show that autologous reconstruction was associated with higher risk of necrotic complications. Although the reconstruction groups differed in BMI, neoadjuvant chemotherapy, and comorbidities, the latter two were not associated with MSFN in the univariate regression model. Therefore, the best explanation for the increased risk of necrotic complications in the autologous group is the high BMI. BMI[8],[9],[24] and WBR[9],[15],[16],[25],[26],[27] have been shown to be associated with MSFN and NAC necrosis. Since BMI was significantly higher in the autologous reconstruction group, this may explain the relatively higher rates of necrosis in this group. Although we do not have a record of the WBR, this variable usually correlates with BMI.[15] Higher breast volume may be associated with longer distance from the source of blood supply resulting in compromised vascularization following mastectomy.

Even though our results showed autologous reconstruction to have a higher risk for necrotic complications, it should be kept in mind that this method is less likely to result in reconstruction failure compared to implant-based reconstructions. Patients with autologous reconstruction who experience MSFN can be managed in the outpatient clinic with debridement, wound care, and – if necessary – skin grafting. However, full-thickness necrosis in an implant patient will require an implant exchange and possibly a local skin/muscle flap for coverage. Whether any of these methods delay adjuvant therapy should further be investigated.

One of the strongest aspects of our study was that all mastectomies were performed by a single surgeon. Differences in surgical competence between surgeons may affect the outcome as pointed out by Ahn et al.[28] On the other hand, our data were not adjusted according to the year of surgery. As experience may affect a surgeon's skill, it serves as a limitation of this study.

Contrary to some reports in the literature, prior radiotherapy[17],[29] was not a risk factor for necrotic complications in our series. Only 13.2% of our patients had a history of radiation, which may have precluded us from reaching a significant result. Laporta et al. have reported that patients who had undergone NSM within 5 years of radiotherapy were more at risk of complications when compared to patients who had surgery more than 5 years after radiation.[17] Although their results did not reach statistical significance similar to our results, this should be kept in mind when deciding for a reconstructive method.

The studies that associated smoking habits with mastectomy skin necrosis included patients who are active smokers.[12],[14] Smoking history in our series was not related to MSFN or NAC necrosis. This may be explained by the fact that we have included all patients with a history of smoking independent of their current status.

Several series have reported incisions involving the areola with lateral or medial extensions to be predictive of necrosis.[28],[16],[14],[12],[28],[29],[30],[31] In their meta-analysis, Daar et al. have demonstrated peri-areolar incision as a significant risk factor for NAC necrosis.[22] Our series showed necrosis rates of 30.1%, 31.7%, and 21.5% for IMF, vertical, and lateral incisions, respectively. Although the incision selection did not have a significant effect on necrotic complications, IMF incision showed a higher rate of necrosis compared to the lateral incision. Throughout the years, our incision preference shifted from lateral incision to IMF incision for appropriate cases due to the risk of lateralization of the NAC. IMF incision is a relatively newer approach. Improvement in outcomes requires a learning curve. In addition, in this technique, more surgical retraction is necessary for better visualization and access to superior borders which may result in damage to the subdermal vascular plexus.

  Conclusion Top

The retrospective review of our 243 patients with NSM and immediate reconstruction revealed that 28% of our patients experienced either partial or full-thickness necrotic complication. The reconstruction method was found to be associated with MSFN most likely due to higher BMI in the autologous group. When deciding for a reconstructive method, careful consideration is needed for patients with higher BMI, keeping in mind that necrotic complications can be more easily managed in autologous reconstruction. In addition, patients with compromised skin perfusion should be considered for tissue expander placement. In order to better justify our recommendations to patients, further studies are needed to investigate whether the reconstruction method – due to necrotic complications – is associated with a delay in adjuvant therapy.


The authors would like to thank Asli Selim, Ph.D. for her contribution on statistical analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Petit JY, Veronesi U, Orecchia R, Curigliano G, Rey PC, Botteri E, et al. Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia. Ann Oncol 2012;23:2053-8.  Back to cited text no. 1
de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: The Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol 2011;18:3117-22.  Back to cited text no. 2
Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol 2011;18:1665-70.  Back to cited text no. 3
Spear SL, Willey SC, Feldman ED, Cocilovo C, Sidawy M, Al-Attar A, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg 2011;128:1005-14.  Back to cited text no. 4
Moyer HR, Ghazi B, Daniel JR, Gasgarth R, Carlson GW. Nipple-sparing mastectomy: Technical aspects and aesthetic outcomes. Ann Plast Surg 2012;68:446-50.  Back to cited text no. 5
Didier F, Radice D, Gandini S, Bedolis R, Rotmensz N, Maldifassi A, et al. Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Canc Res Treat 2009;118:623e33.  Back to cited text no. 6
Matsen CB, Mehrara B, Eaton A, Capko D, Berg A, Stempel M, et al. Skin flap necrosis after mastectomy with reconstruction: A prospective study. Ann Surg Oncol 2016;23:257-64.  Back to cited text no. 7
Crowe JP Jr., Kim JA, Yetman R, Banbury J, Patrick RJ, Baynes D, et al. Nipple-sparing mastectomy: Technique and results of 54 procedures. Arch Surg 2004;139:148-50.  Back to cited text no. 8
Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting postoperative complications following skin sparing mastectomy with immediate breast reconstruction. Breast 2011;20:21-5.  Back to cited text no. 9
Lohsiriwat V, Rotmensz N, Botteri E, Intra M, Veronesi P, Martella S, et al. Do clinicopathological features of the cancer patient relate with nipple areolar complex necrosis in nipple-sparing mastectomy? Ann Surg Oncol 2013;20:990-6.  Back to cited text no. 10
Cho JW, Toon ES, You HJ, Kim HS, Lee BI, Park SH, et al. Nipple-areola complex necrosis after nipple-sparing mastectomy with immediate autologous breast reconstruction. Arch Plast Surg 2015;42:601-7.  Back to cited text no. 11
Algaithy ZK, Petit JY, Lohsiriwat V, Maisonneuve P, Rey PC, Baros N, et al. Nipple sparing mastectomy: Can we predict the factors predisposing to necrosis? Eur J Surg Oncol 2012;38:125-9.  Back to cited text no. 12
Frey JD, Alperoxich M, Levine JP, Choi M, Karp NS. Does smoking history confer a higher risk for reconstructive complications in nipple-sparing mastectomy? Breast J 2017;23:415-20.  Back to cited text no. 13
Garwood ER, Moore D, Ewing C, Hwang ES, Alvarado M, Foster RD, et al. Total skin-sparing mastectomy: Complications and local recurrence rates in 2 cohorts of patients. Ann Surg 2009;249:26-32.  Back to cited text no. 14
Ito H, Ueno T, Suga H, Shiraishi T, Isaka H, Imi K, et al. Risk factors for skin flap necrosis in breast cancer patients treated with mastectomy followed by immediate breast reconstruction. World J Surg 2019;43:846-52.  Back to cited text no. 15
Park S, Yoon C, Bae SJ, Cha C, Kim D, Lee J, et al. Comparison of complications according to incision types in nipple-sparing mastectomy and immediate reconstruction. Breast 2020;53:85-91.  Back to cited text no. 16
Laporta R, Longo B, Sorotos M, Farcomeni A, Patti C, Mastrangeli MR, et al. Breast reconstruction following nipple-sparing mastectomy: Clinical outcomes and risk factors related complications. J Plast Surg Hand Surg 2017;51:427-35.  Back to cited text no. 17
Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg 2018;153:891-9.  Back to cited text no. 18
Jagsi R, Jiang J, Momoh AO, Alderman A, Giordano SH, Buchholz TA, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol 2014;32:919-26.  Back to cited text no. 19
Sacchini V, Pinotti JA, Barros AC, Luini A, Pluchinotta A, Pinotti M, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: Oncologic or technical problem? J Am Coll Surg 2006;203:704-14.  Back to cited text no. 20
Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki WM, Costa A. Necrotic complications after nipple- and areola-sparing mastectomy. World J Surg 2006;30:1410-3.  Back to cited text no. 21
Daar DA, Abdou SA, Rosario L, Rifkin WJ, Santos PJ, Wirth GA, et al. Is There a Preferred Incision Location for Nipple-Sparing Mastectomy? A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019;143:906e-919e.  Back to cited text no. 22
Saçak B, Önal M. COVID-19 Pandemic and Categorization of Plastic Reconstructive and Aesthetic Surgeries during the COVID-19 pandemic. In: Demirdöver C, ed. Plastic Surgery and COVID-19. 1st Ed. Ankara: Turkish Clinics; 2020. p.20-9.  Back to cited text no. 23
Longo B, Laporta R, Sorotos M, Pagnoni M, Gentilucci M, Santanelli di Pompeo F. Total breast reconstruction using autologous fat grafting following nipple-sparing mastectomy in irradiated and non-irradiated patients. Aesthetic Plast Surg 2014;38:1101-8.  Back to cited text no. 24
Woerdeman LA, Hage JJ, Hofland MM, Rutgers EJ. A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria. Plast Reconstr Surg 2007;119:455-63.  Back to cited text no. 25
Munhoz AM, Aldrighi CM, Montag E, Arruda EG, Aldrighi JM, Gemperli R, et al. Clinical outcomes following nipple-areola-sparing mastectomy with immediate implant-based breast reconstruction: A 12-year experience with an analysis of patient and breast-related factors for complications. Breast Cancer Res Treat 2013;140:545-55.  Back to cited text no. 26
Chirappapha P, Petit JY, Rietjens M, De Lorenzi F, Garusi C, Martella S, et al. Nipple sparing mastectomy: Does breast morphological factor related to necrotic complications? Plast Reconstr Surg Glob Open 2014;2:e99.  Back to cited text no. 27
Ahn SJ, Woo TY, Lee DW, Lew DH, Song SY. Nipple-areolar complex ischemia and necrosis in nipple-sparing mastectomy. Eur J Surg Oncol 2018;44:1170-6.  Back to cited text no. 28
Colwell AS, Tessler O, Lin AM, Liao E, Winograd J, Cetrulo CL, et al. Breast reconstruction following nipple-sparing mastectomy: Predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg 2014;133:496-506.  Back to cited text no. 29
Carlson GW, Chu CK, Moyer HR, Duggal C, Losken A. Predictors of nipple ischemia after nipple sparing mastectomy. Breast J 2014;20:69-73.  Back to cited text no. 30
Frey JD, Salibian AA, Levine JP, Karp NS, Choi M. Incision choices in nipple-sparing mastectomy: A comparative analysis of outcomes and evolution of a clinical algorithm. Plast Reconstr Surg 2018;142:826e-35e.  Back to cited text no. 31


  [Table 1], [Table 2], [Table 3]


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