Simplifying the challenging breast for a successful NSM/DIR. Reverse engineering meets reconstructive surgery

Gudjon L Gunnarsson & Jørn Bo Thomsen Telemark Hospital, Norway & Odense University Hospital and Lillebaelt Hospital, Vejle, Denmark

Nipple sparing mastectomy (NSM) with direct to implant reconstruction DIR has become the gold stand-ard for prophylactic one stage approach. It is simple, safe and allows for other more advanced options. Published and presented data often reveals impressive results and few complications.

Patient selection is the key to success for achievement of optimal results and few complications. Often however, the published data is more valuable for the many then the few and in our experience based on more than 300 direct to implant NSM reconstructions using every available method we've noticed that patients with macromastia and severely malformed breasts remain a challenging group to treat satisfacto-rily. Corrective procedures are difficult and reconstructive failure is unacceptably high.

Inspired by Scott Spear we applied the thought process of reverse engineering and decided to shape the breast prior to the conclusive NSM and immediate breast reconstruction at a later stage. We performed a prospective cohort study on this particular group of patients; patients scheduled for risk reducing NSM and DIR; patients with macromastia, asymmetry, malformed or severely ptotic breasts and enrolled them in a different two stage approach, shaping the breast to fit the individual patient’s footprint, narrowing the wide areola and preconditioning the vascular flow of the skin flaps. Then in a secondary attempt we performed the mastectomy/reconstruction in our standard fashion. The detailed scientific content of this paper is accepted for publication in the PRS. We wish to present the results of our approach to in-spire others facing a similar challenge.