Breast Reconstruction after Nipple-Sparing Mastectomy in the Large and/or Ptotic Breast: A Systematic Review of Indications, Techniques and Outcomes

ABSTRACT Background Surgeons remain reluctant to perform nipple-sparing mastectomy in large breasts due to a higher risk of necrosis. We performed a systematic review of the literature to evaluate indications, techniques and outcomes in immediate or delayed breast reconstructions in large and/or ptotic breasts. Methods The following search terms were used for both titles and key words: [nipple sparing mastectomy AND ("breast ptosis" OR "ptotic breast" OR “large breast” OR “breast hypertrophy” OR “gigantomastia”)]. All forms of breast reconstruction in large and/or ptotic breasts from 1990 through September 1st 2018 reporting indications, techniques and outcomes were included. Results Thirty-one studies met the inclusion criteria, yielding 1128 nipple-sparing mastectomies (709 immediate and 419 delayed) in 629 patients for analysis. The overall complication rate was 29,08 percent. The mastectomy flap necrosis rate was 12 percent, the partial NAC necrosis 11 percent and the complete NAC rate 11 percent. The overall complication rate in one-stage versus delayed reconstructions was 37,52 versus 14,8 percent. The incidence of necrosis in one-stage versus delayed reconstructions was 5,36 versus 2,15 percent for partial, 5,08 versus 0,48 percent for complete NAC necrosis and 4,8 versus 1,43 percent for skin flap necrosis. Conclusions The majority of studies being small and retrospective as well as the large variation in outcomes indicates that we lack consensus on timing of reconstruction or ideal technique. A noticeable difference in skin flap and NAC necrosis however is seen in favor of NAC delayed procedures. Randomized controlled trials are mandatory to prove this difference significantly.