Direct-to-Implant versus Immediate Free Flap Reconstruction after Nipple-Sparing Mastectomy: A Propensity Score–Matched Analysis

Abstract

Background: Both direct-to-implant (DTI) and immediate free flap (FF) breast reconstruction following nipple-sparing mastectomy (NSM) have been described in the literature. However, there is a paucity of comparative studies between these two techniques. Furthermore, existing studies do not control for factors influencing ischemic complications. Methods: A retrospective review of all NSMs performed at a single institution between January of 2014 and January of 2020 was performed. Immediate FF reconstructions were propensity score matched using probit regression to identify a comparable DTI cohort based on mastectomy weight, smoking, age, and history of radiotherapy. Primary outcomes of interest were 30-day ischemic complications. Results: One hundred eight NSMs performed in 79 patients were included. Average age was 45.7 ± 10.5 years and mean body mass index was 27.1 ± 4.8 kg/m2. There were 54 breasts in both the DTI group and the immediate FF group. Median mastectomy weight in the DTI group was 508 g (interquartile range, 264 g) as compared with 473 g (interquartile range, 303 g) in the FF group (P = 0.792). There was no significant difference in the rate of partial nipple-areola complex necrosis in the DTI and FF groups (5.6% versus 3.7%, respectively; P = 0.500) or mastectomy flap necrosis (5.6% versus 11.1%; P = 0.297). Both the DTI and FF groups had a total nipple-areola complex necrosis rate of 1.9% (P = 0.752). Conclusion: Both DTI and immediate FF reconstruction can be safely offered to patients undergoing NSM while providing the benefit of a single reconstructive procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.