covers a technique for breast reconstruction that offers women with preoperative breastosis the possibility of nipple preservation. As recently as two decades ago when I began my reconstruction practice, concepts such as pre-pectoral reconstruction, direct-to-implant reconstruction, nipple sparing mastectomies, and fat grafting and breast reconstruction were relatively foreign. They have now become quite commonplace. As it relates to nipple sparing mastectomies, more and more women are found to be candidates from an oncologic standpoint. This is largely due to the fact that with each evolution in the surgical treatment of breast cancer, there's been a move in this direction of tissue preservation. This poses a challenge to a reconstructive surgeon, particularly when the patient presents with preoperative breastosis. In 2020, we published a paper in PRS describing a technique of direct-to-implant breast reconstruction with concurrent nipple sparing mastopexy based on an inferior adipodermal pedicle. The key takeaways of this paper, as well as this presentation, are that women with preoperative ptosis may indeed be candidates for direct-to-implant reconstruction with nipple sparing mastopexy addressing their ptosis at the time of the reconstruction without the need for a staged procedure such as a pre-mastectomy lift or reduction. As with any surgical procedure, patient selection is critical in order to maximize outcomes and minimize complications in these patients. We found that patients with either second or third degree ptosis may be candidates for this procedure based on a number of factors. One key factor is the nipple to inframammary fold distance relative to the base diameter of the breast. We found that a nipple to fold distance that is at least two centimeters less than the base diameter is a reasonable parameter for determining candidacy. It's important to remember that these are essentially random flaps and therefore length-width relationships of random flaps to apply. For example, a patient with a breast base diameter of 14 centimeters should have a nipple to fold distance of no more than 12 centimeters in order to be considered a candidate for this nipple sparing mastopexy procedure. There is a maximum nipple to inframammary fold distance of 14 centimeter regardless of the patient's base diameter. In other words, no patient with a nipple to fold distance of over 14 centimeters should be considered a good candidate for this procedure. Other factors include patients who have nipple position asymmetry. This is most appropriately applied to non-smokers, of course patients who are oncologic candidates, and patients who have not had a prior mastopexy or reduction by any technique. Standard Y's pattern markings for the procedure are shown here. A couple of takeaway points include not committing to the circular portion of the Y's pattern. This is done after the inverted T is closed, the patient can be positioned upright, and templates cut from a blue towel can be used to ensure that proper nipple areolar position is achieved and best symmetry as well. A second important point I believe is that the divergence of the vertical limbs of the Y's pattern or the upside down V should be as wide as possible. This maximizes blood flow through the inferiorly based adipodermal pedicle to the nipple, which although in this case is quite low, often sits at the apex of that V. Too narrow a divergence will limit blood flow to the nipple areolar complex. Intraoperative sequencing is as follows. Initially the nipple areolar complex is marked. I prefer a 38 millimeter cookie cutter, but a 45 millimeter cookie cutter could also be used. The entire Y's pattern is then de-epithelialized. It's important to note that this differs from a standard inferior pedicle technique where only a certain segment of the inframammary fold would be de-epithelialized with full thickness resections medially and laterally. In this case, once again in order to maximize the length width ratio of this random flap, the entire length of the inframammary fold should be utilized. Thus the entire Y's pattern is de-epithelialized. Full thickness dermal incisions are then made superiorly, medially, and laterally, preserving the entire inframammary fold as an inferiorly based pedicle, containing the nipple areolar complex at its distal end. The mastectomy is then performed in standard fashion, elevating both the superiorly based flaps, which are epithelialized, as well as the inferiorly based flap, which is de-epithelialized, preserving an appropriate thickness of the flaps. Here are some intraoperative photos from our publication. On the left, you see the fully de-epithelialized Y's pattern with a 38 millimeter cookie cutter used to mark the nipple areolar complex. On the right, you see the elevation of the flap post-mastectomy. Note that the circular portion of the Y's pattern that will be used for inset of the nipple areolar complex is not yet committed to. I think this is very important to allow for minor adjustments to achieve the best possible nipple position, as well as the best symmetry. Final implant size selection is also an important component of achieving good results with minimal complications. In general, final implant size should mimic the weight of the mastectomy specimen. If the patient desires a slight increase or decrease in volume, those can typically be accommodated, but major deviations from the mastectomy weight in terms of final implant size should be avoided. Implants are placed in the pre-pectoral space and alloderm is used. Either anterior coverage or full wrapping are appropriate. I also recommend the use of antibiotic beads to help prevent post-operative infections, particularly implant infections. A single JP drain is used on each side, and the drain is left in for a minimum of two weeks to facilitate incorporation of the ADM. The Y's pattern closure is completed, as would be done for any Y's pattern, and a non-compressive dressing is used. Regional blocks with X-Borrel can also be utilized. This helps not only with post-operative pain control, but allows a number of these patients to have their surgeries performed in an outpatient setting. This slide demonstrates an intraoperative photo following placement of the implant in the pre-pectoral space and coverage with anterior ADM. A drain has been placed and the inferiorly based adipodermal pedicle containing the nipple areolar complex at its apex has reflected inferiorly, in this case to the left of the photo. The inferiorly based pedicle is then reflected superiorly to cover a portion of the implant and ADM, and Y's pattern closure is completed to include inset of the nipple areolar complex. Shown here are intraoperative photos after final closure. Shown here is a one-year follow-up of a patient who had a single operation with no revisions. Here are her lateral views. Here is a unilateral case. In this case, the patient had left-sided breast cancer and underwent immediate direct-to-implant reconstruction with nipple-sparing mastopexy based on inferior adipodermal pedicle on the left side with an augmentation mastopexy on the right for symmetry. This slide demonstrates partial necrosis of both nipple areolar complexes, slightly worse on her left side. It also demonstrates scabby healing at the inverted T or the junction of the vertical limb and the inframammary fold incisions, which is quite common. One additional benefit of this procedure is that any viability of the nipple areolar complex ensures that the tissue deep to that inverted T closure is viable, and these can often be managed with simple topical wound care and rarely require debridement or closure. In this case, even the nipples went on to heal without the need for additional surgery. Here she is at six months. Once again, no debridement or additional surgery was required. She had topical treatment with sylvadine as well as hyperbaric oxygen to facilitate her healing. In summary, with increased numbers of patients who are oncologic candidates for nipple sparing mastectomies, reconstructive surgeons can now deal with patients with preoperative ptosis and allow them to have nipple preservation. Patients who are good candidates should have a favorable nipple to inframammary fold distance, particularly relative to the base diameter of the breast. They should be non-smokers, they should be oncologic candidates for nipple sparing mastectomy, and they should have no prior history of mastopexy or breast reduction by any technique. Important aspects of the procedure that will help achieve optimal outcomes with minimal complications include using the entire inframammary fold length for the base of your inferiorly based pedicle. A wide divergence of the vertical limbs of the Weiss pattern is also favorable, again, to preserve blood flow to the nipple areolar complex at its distal tip. Utilizing an implant that is close to the mastectomy weight will allow for tension-free closure and minimize the risk of mastectomy skin flap loss. The use of antibiotic beads and experil for post-operative pain control are also advantageous. Thank you. Thank you so much for having me. It's a pleasure to participate in this panel. I'm going to talk about superiorly based mastopexy with direct-to-implants reconstruction. I have no financial disclosures. A little bit about my private practice. Over 50% of my practice is breast reconstruction, of which all is implant-based. I don't offer autologous reconstruction anymore. I am able to go directly to implant 90% or more of the time, and recently, in the last six years, it's been pre-pectoral reconstruction. And I can only show you what I'm showing here today because I work with three fabulous and exceptional breast surgeons that leave me great flaps. So, when it comes to managing these tautic breasts, the literature says that we should stage our mastopexies and reductions for safety. And I'm sure, if they haven't already discussed it, we're going to be hearing about that from some of the other panelists. But are more procedures actually safer for these patients? I don't know about y'all, but in Texas, it's becoming more and more challenging to get pre-authorization for staged procedures and reimbursement. So, it's become important to me to try to combine as much as I can in as few procedures as possible. And it's really kind of created this environment where I tend to approach these patients with a very aggressive algorithm. The algorithm has evolved based on help from the literature. Dr. Mosharrafa's article on inferiorly based adipodermal flaps was lovely to see back in 2020, as well as Deidre Amorea's team's article on vertical skin-only mastopexies. I think one of her limitations in this article is that she could only move the nipple about four centimeters, but still that was better than nothing. The batwing mastopexy and smile mastopexy articles also show kind of a similar superiorly based blood supply, but commit the patient to a transverse scar, which I don't find as aesthetically appealing. So, it's been an evolution for me to kind of expound upon the superiorly based mastopexy option and develop my own algorithm. And I've come up with a few simple rules to follow when it comes to attempting these. When it comes to assessing the patient, if they're not complaining about their nipple position or their breastosis, I am NOT trying to go to heroic measures to change their minds about that. And so, I tend to leave them as they came to me. You can get a little bit of nipple repositioning with these direct-to-implant prefectural reconstructions, and the way that I work that is with the help of the tegaderm bra. And this is not my concept, this is my interpretation of this concept. I use about seven of the long, skinny, what I call megaderms, which are the long tegaderms. And I do clean their skin with alcohol first. I reposition the nipples where I think they need to be positioned, and then I'm putting the tegaderms down. Word of caution that you do have to get all the way out to the mid-axillary line to prevent blistering, and you do have to protect the nipples. I use cotton eye pads stacked up, my residents call this a nipple C-collar, to prevent the nipples from being folded over and creating an ischemic compromise situation. I like these because the patients can shower over the top of them, and it does provide me some securing of their skin flaps. These come off after 10 to 14 days when the drain tubes are removed. My second role is if the patient wants to lift her breast or readjust her nipple appearance, I always make them smaller. I never let them talk me into a larger implant. And in this situation, you do have to decide on where you're going to position that derbal pedicle. And so it's evolved for me, but I've finally determined that if I'm moving the nipple less than six centimeters superiorly, I'm going to base the blood supply to the nipple complex on a superior adipodermal pedicle. If I'm moving the nipple more than six centimeters, then I'm going to base that pedicle inferiorly, like Dr. Mosheroff's article has suggested. So this is a couple of case examples. I'm going to kind of walk you through step by step how I do these. When I'm marking these, I mark them the day before in my office so that I can make sure that I communicate well with the breast surgeon as to their incisional approach. So when I'm basing it superiorly, I let the breast surgeon choose between an inferior vertical or an inframammary fold incision for access, and it kind of depends on their level of skill and preference will determine which one they choose. But I give them the options. I always use spiangiography very liberally during these procedures, sometimes doing it two or three times. I always start with the angiography at the beginning of the case before I've done any manipulation of the tissue just to see where we are. And in this case, you can see that I've marked in that upper outer quadrant area where the spi numbers were a little bit on the lower side, but certainly not concerning. And you can see the lymphodurin die. So I use an inflatable saline sizer that's disposable. These are relatively cheap, and you can fill them with air or saline, your choice. I choose air just for speed. And then I'm tailor tacking based on my preoperative markings around this sizing implant, and usually I'm filling up that implant to the volume of the tissue that was removed or smaller, depending on the patient's wishes. You can see how much vertical and horizontal laxity is going to be removed with the course of this procedure. Then I'm removing the staples, and then this is where I have to de-epithelialize. And there's varying degrees of release that I will perform depending on where the nipple falls relative to the keyhole of the mastopexy. So if I'm well below the keyhole, there's going to be a need for my most aggressive version of this procedure, which is where I have to make some dermal cuts that create truly a superiorly based adipodermal pedicle. So going from 3 o'clock and 9 o'clock in that keyhole all the way down to the incision line is where I'm making my dermal cuts. So you can see here that I've made the dermal cuts, and you can appreciate the robust nature of the mastectomy flaps that I'm left to work with, which is probably the key to my success is these nice healthy flaps. I will spy a second time at this juncture and identify whether or not all or some of this flap that I've created are going to survive. So if everything below this line is not viable, I don't mind discarding that tissue to unburden my blood supply, but if it's viable I like to keep it. I'll fire a couple of vicryls across that portion and then I tuck it in under the vertical limb of my closure because it provides a little better contour. If I have to get rid of it though, I don't mind. If everything below this line is not viable, I'm removing the whole flap and keeping the nipple to paste on as a free nipple graft onto that dermis that I preserved. So you haven't burned any bridges, you've kept some safety nets in play, and so I've learned these the hard way. These safety nets are important. And so just to show her before and afters, this is her with a direct implant, 485 cc implant with an ADM route to anchor it, tucked in. Here's her side view. A patient like this second case, it would be a good one to start attempting these procedures on. She's going to fall into the easiest category of skin-only mastopexy where you don't have to make any dermal cuts. You simply just have to deepithelialize because her nipple falls within the keyhole. You really don't have to do any dermal cuts because you don't need to excurse or remove the nipple as much. And so you can see from her before and after, you can see just removing that lower skin redundancy without having to elevate the nipple very much gives her a nice contour. A patient like this is kind of the middle range of the version that I do. When you do her markings and deepithelialization, you'll see that her nipple falls kind of right on that keyhole opening line. And if you try, I always will try to close these without having to do any cuts at all, usually by putting a stitch in the 12 o'clock at the nipple and pulling it up into that keyhole and tailor tacking the vertical limbs closed. But usually what will happen on these that are spanning that dotted line of the keyhole is that you'll get a lot of buckling in that six o'clock position. You can't elevate those corners very easily. And so undoing it, you will have a chance to release the corners just enough that you can get the keyhole closed without any significant buckling. But you don't have to take that dermal cut all the way down. Here's her before and her markings. Her side view. Again, once again, showing you the most aggressive version for this particular patient. You can see with her tailor tacking and her keyhole that her nipple falls well below her keyhole. So she needs full thickness dermal cuts all the way down in order to get this to work. And this is her before and after side view. Just a few more cases showing before and afters of this technique. You can see the markings in side view. It works well on smaller-breasted patients like this one, just to tighten up the envelope. Larger BMI patients, it is safe on. I've got one breast surgeon that will go to a BMI of 35, and another one that will go all the way up to a BMI of 42 with me on nipples carrying mastectomies. Asymmetry cases, it is super helpful. And if I have to move that nipple more than 6 centimeters, I am working with an inferiorly-based pedicle, which Dr. Mushabrata is going to talk about if he hasn't already. So third rule is always consent for those free nipple grafts. You never know when you need them. This particular patient needed a free nipple graft just on that left nipple, because on final spy, it showed poor perfusion. In dismantling the flap, I noticed that the breast surgeon had gotten very, very thin in the area of the keyhole. And so everything below that line came off. And free nipple graft happened. And it was interesting, just doing it unilaterally, how much shape difference there is when you don't have all that extra tissue to tuck in underneath the nipple complex. It does look quite flat compared to the other breast. So she did require some additional fat grafting. I'm sorry, my head is covering the text here. But fat grafting to restore some of that contour underneath the nipple on the left-hand side. So a couple of pearls and pitfalls. The nipple default length doesn't change with time. And what I mean by that, I'll show you in a case here just in a second. And there's no secondary areolar widening, which you might see on a straightforward neostopexy. So be very cautious as you're cutting out those nipples to inset them. So where I learned that the nipple default length doesn't change with time was on this patient. She was a prior cosmetic implant patient with a dual-plane 600cc high-profile implant in place, and was a candidate for a right nipples-faring mastectomy, and only wanted a right mastectomy. And so I'm doing some quick math in my head saying, okay, she's got 600cc subpectral implants. She's got a 300 gram or so breast on top of that implant. That's a 900cc deficit. I'm not gonna be able to find an implant big enough to make up for that. So I'm gonna have to do some soft tissue tightening on that side to address her soft tissue envelope. And then if I'm successful on that cancer side, I'm gonna have to do something on the left-hand side as well to manage. And the kicker here is that she has animation deformity with her cosmetically-placed implants. And for me, that's an automatic site change to prepectral. And so I told her when I went into surgery that I was gonna try to do a nipple-faring mastectomy direct-to-implant site change to prepectral on her cancer breast with a mastopexy superiorly based. And if I was successful at doing that, at the same time I would do a site change to prepectral on her non-cancer side with a mastopexy to match using differential implant volumes to get the best result that I could. And while I don't have an on-table picture of her, my nipple-to-fold lengths were perfect on both sides. Volume was perfect on both sides. And when she came back to see me at three months, this is what she looked like, no longer perfect. And it was a very important lesson because I normally set that nipple-to-fold length a little on the short side because I expect some secondary stretch deformity to happen. And that's exactly what happened on the aug-pexy side. I got a nice relaxation of the lower pull, the nipple elevated a little bit, nipple widened a little bit. On the cancer side, she had no relaxation of that nipple-to-fold distance and that nipple didn't widen at all. And I fixed her animation deformity by site changing her to prepectral, that's her flexing in that bottom right picture. But she's had some rippling and I told her, let's go back to do some fat grafting for the rippling. And if you'll let me have a second chance at that left side, I will redo the pexy and tighten up so you have a better symmetry. And so this is what she looked like a year after her revision. And she was accepting of a slightly lower nipple position than what I would like, but just to get her some symmetry. So following her out, this is her before. This is her at three months with the asymmetry. This is her at one year after the revision. And this is her at actually two years, sorry, my head's covering the text here, with a 20 pound weight gain on her estrogen blocker. But you can still see that nipple-to-fold length never adjusted at all. The breast relaxed a little, but the nipple-to-fold distance didn't change. So learning from that, I now set the nipple-to-fold length a little longer than I would for my cosmetic patients. And here's another example. This patient had 800 cc cosmetically-placed subpectral implants with a prior mastopexy. She's a Dallas socialite, where bigger is obviously better. And was a candidate for bilateral nipples-faring mastectomy, carries a genetic mutation in addition to her left-sided cancer, and had a direct-to-implant 770 cc site-changed prepectral with superior-based mastopexy. This is her animating in the bottom right. And following her out, that's her before on the left, her at six months in the middle, and her at two years on the far right. And looking at that nipple-to-fold length, again, prior, six months, and two years, you can see not much changes over the course of time with the nipple-to-fold length. So what to do when things go wrong. I like this because it's not a dream home if it doesn't clean itself. So what makes me wanna burn the whole house down? Well, obviously, nipple compromise. And a couple pearls on this is, when you have partial nipple compromise, this patient, and these are her markings, superiorly-based, I thought you'd need to move the nipple. So she was a skin-only mastopexy. When I took off her tegaderm bra at 10 days, she had inferior areolar compromise on the right breast. And I do sit on these just for a few extra days to let the tissue demarcate. I don't normally recommend sitting on any pre-pectoral reconstruction with any skin compromise. But on these, I like to let them really demarcate. As you can see, I was able to not have to remove as much tissue. But words to the wise, if you just debride the skin that's causing a problem, you are very likely leaving behind all of the additional fat and fat necrosis that likely happened from that point down. So you do have to go in and kind of carve out all of that fat necrosis. And you'll find it's not adherent to the ADM of your implant at all because it's not vascularized, so it can't adhere. But I usually just debride it, irrigate really well, and close up shop. And that's what I did on this particular patient. And this is her at one year with no additional measures made other than the removal of that small cuff of her areola. A bigger problem is a patient like this who underwent bilateral and superiorly-based flaps, direct-to-implant. She is set to have radiation on that left breast, so I intentionally left it a little looser and lower in preparation for radiation. And spine numbers showed everything looked great intraoperatively. When she came back to see me, that's her intraoperative picture. Took off her tegaderm, brought the two-week mark and partial thickness on the right nipple complex and full thickness on the left nipple complex. And I sat on it for a few extra days as per my usual. And she unfortunately developed a rip-roaring infection on that left side. And knowing that she needed adjuvant chemo and radiation, I had to get her to her treatment on time. So I ended up removing the ADM-wrapped implant, closing the skin. And between adjuvant chemo and radiation, was able to place a tissue expander before she got to radiation. So I was able to salvage that soft tissue envelope a little bit. She's due for her exchange here soon. So when it comes to the superiorly based mastopexies with direct implant, like this picture shows, you gotta do what you feel comfortable with. Not everybody's gonna have breast surgeons that leave viable enough flaps to attempt these techniques with. But if you've got a good breast surgeon that you want to collaborate with and can combine procedures, I think it's worth doing. If you have questions or like to email me, you can contact me at any time. Here's my email. Thank you so much. Hi, everyone. My name is Chris Cavanzanis. I'm a plastic surgeon at the University of Colorado. My talk is on strategies for autologous breast reconstruction following nipple-sparing mastectomy in patients with significant ptosis. Nothing to disclose. So the American Cancer Society estimates more than 300,000 new cases of invasive breast cancer in the U.S. in 2024, with mastectomy being a commonly used treatment modality in more than a third of these cases. Over the last couple of decades, we've also seen an increase in the number of prophylactic mastectomies. Approximately 40% of women undergoing mastectomy elect to receive breast construction. Of those, roughly a fifth will have autologous breast construction with an increase in the number over the last few years for various reasons. Various types of autologous reconstruction exist, including several downsides, such as the abdomen, as you can see here, thighs, as well as buttock. It is becoming a more attractive option for many patients as it preserves the natural breast shape and contour while avoiding the complications related to the implants. When it comes to mastectomies, several studies have demonstrated the superiority of nipple-sparing mastectomies compared to skin-sparing mastectomies as it relates to psychosocial and sexual well-being, body image, feeling of mutilation, and satisfaction with the appearance of the nipple. Some others, however, do not show any significant difference between nipple-sparing mastectomy and skin-sparing mastectomy with reconstruction of the nipple area complex, and this could be related to the complication associated with the NAC after nipple-sparing mastectomies. Certainly, women with large and tautic breasts represent a challenging subgroup of patients, and in the literature, reconstruction of tautic breasts is often associated with increased surgical complications, particularly for NAC necrosis that can result in poor surgical outcomes. Interestingly, a review of the American Society of Breast Surgeons Nipple-Sparing Mastectomy Registry demonstrated that of nipple-sparing mastectomies performed, only about 15% were in patients with great teetosis, and 3.9% in patients with great teetosis, so very low numbers. But I think the challenges are there for most degrees of ptosis, including parenchymal maldistribution. And of course, the aim of the reconstructive surgeon is not only to restore the lost volume and skin after mastectomy, but also to provide an aesthetically pleasing and symmetric result that is long-lasting with minimum morbidity and least amount of stages, right? And this can be challenging in patients with tautic breasts, and different approaches have been proposed over the years to tackle this difficult task. And over the next few slides, I'll go through the various tautic reconstruction options for this patient population. So in terms of time, we'll have one-stage procedures and two-stage procedures, and I'll go through all of them in detail, but one-stage procedures essentially include nipple-sparing mastectomy with pedicle NAC, and skin-sparing mastectomy with NAC grafting, and two-stage procedures involve nipple delay, pre-mastectomy reduction mastopexy, as well as post-mastectomy mastopexy. Let's start with our first one. During this procedure, the mastectomy, autologous breast reconstruction, as well as mastopexy are all performed as a one-stage procedure, and during surgery, an inferiorly based vascularized dermal flap that includes the NAC is preserved, and this is also referred by some as the deep ethylized Weiss pattern skin reduction. So the mastopexy essentially is performed through a Weiss pattern limb. Then an areolosizer is used to establish the diameter of the areola, and the inferior skin flap is deeply ethylized. And you can see that here. Once this is completed, then the breast pocket is established, and the deep flap, or whatever other flap is selected, is basically harvested, and that's the most in a standard fashion, and then the dermal flap is basically infolded over the flap, and if desired, you can secure the dermal flap in place with several sutures, and then the superior skin flaps are basically advanced over the dermal flaps, and finally, the NAC is redirected to the breast mount through a keyhole area of deep ethylized skin flap, basically inset, as you can see here. Other similar approaches have been described, and they're referred to as reduction mastopexy approaches. This photo shows the pre- and post-operative markings for simultaneous nipple-sparing mastectomy and reduction mastopexy. A boomerang-shaped superior incision is made with lateral and medial extensions, through which the breast tissue and a variable amount of skin can be excised based upon how much lift is needed, and basically, you're trying to decide how far up the nipple complex should be moved, to have a more natural position. With this approach, the NAC is also carried on a broad, inferiorly-based dermal pedicle, and the flap is then inserted into the pocket, and after inset is completed, the edges of the skin are re-approximated. And for all these approaches, you can leave a skin panel that can be excised later, or basically, you can completely bury the flap if you're comfortable with that approach. This is another variation of this approach, using a superior periodontal incision with lateral extension. Because these mastopexy techniques require the maintenance of dermal continuity with the surrounding skin envelope, the amount of nipple complex movement is limited, and the blood supply can be tenuous, leading to postoperative issues, such as nipple complex necrosis. The authors of these studies compare nipple-spanning mastectomy with immediate free flap, to nipple-spanning mastectomy with tissue-expander placement, and noted that the rates of NAC necrosis were 29% for the free flap group, and 0% for the tissue-expander group. And of course, that difference was contributed to the lighter weight of the tissue-expander, and minimization of pressure on the mastectomy flaps. So the take-home message from this is that tissue-expander should definitely be considered for these patients, and in my opinion, my experience especially, if the estimated weight of the flap is above 600 to 700 grams. Here's one of the patients I did recently who had an aggressive cancer, and ended up having neoadjuvant radiation on the left. She preferred autologous reconstruction, however, I felt that her flaps were too big for her skin envelope. That, on top of the recent radiation, made me decide to stage her reconstruction, and use a tissue-expander first for safety reasons. So here you can see an example of this approach, with this picture showing basically the area of depithelialization, and an areola says it has to be used for the new areola, and then the tissue-expander is placed in the pocket, wrapped with ADM, and the dermal flap is wrapped over that. Switching gears a little bit to basically NAC grafting. The use of NAC grafts has been widely described in reduction mammoplasty and mastectomies for chest masculinization in the transgender and gender-diverse populations. And more recently, the use of the free NAC grafts has been described in implant-based reconstruction for correction of basically nipple asymmetry and preservation of the nipple in patients who are eligible for skin-spreading mastectomies, but do not meet criteria for nipple-sparing due to breast size or tumor location. For this approach, the NAC is marked basically with an aerosizer, and is harvested as a full-thickness graft. Ductal biopsies can be performed for immediate reconstruction, for intraoperative fresh-frozen analysis, and for the completion of the flap anastomosis and inset, combination of clinical judgment and angiography is utilized to evaluate the perfusion of the mastectomy flaps to determine if the bed is healthy for grafting of the NAC. And basically, an aerosizer is used at the right location, the sides de-epithelialized to allow inset of the graft. Here's a reconstructive algorithm described by Egan et al to help basically guide decision-making for nipple salvage techniques and determine the graft inset, which is basically based on preoperative and intraoperative considerations. In the interest of time, I won't go through it, but it's a good algorithm to have in mind. Here's an example for that paper, pre- and post-operative frontal photos of patients with buried flaps, and NAC grafting to the mastectomy flaps. Here's another one, an example from that paper with bilateral NAC grafting to the free flaps. Salvaging the patient's native NAC has a benefit of immediate nipple reconstruction without the need, secondary procedures, obviously, and also there's no need for maintenance with tattooing because a tattoo is done typically lasts forever. There's also a cost associated with a secondary procedure that can be avoided, and that's not only financial, but also it could be related to lost time from work and psychosocial consequences for the patients. Although minor complications such as hypopigmentation and depigmentation are common complications requiring further treatment, such as graft loss or delayed healing are rare, and we should not forget that these major complications also occur in nipple-spare mastectomy patients and perhaps at higher rates according to some studies. So the delay phenomenon has been used for hundreds of years to improve blood supply of tissues which are to be transferred, and not surprisingly, it has been described for the tautic breast patient population to reduce the risk of necrosis of the NAC, and Palmieri et al was the first to introduce the two-stage concept of delayed NAC in 2005, and that was mainly for implant-based reconstruction. The first stage was performed on an outpatient basis using tumescence anesthesia and laparoscopic instruments to undermine the NAC in surrounding skin, and basically they did the second stage about three weeks later. Most delayed techniques involve undermining the nipple and surrounding mastectomy skin to some degree. Performing a delayed procedure prior to nipple-spare mastectomy allows the breast surgeon to send a retroarterial biopsy. Why is that important? Because the intra-arterial biopsy Why is that important? Because the intraoperative fresh frozen section is not as accurate as the analysis of permanent sections, and it's important to do that as a critical step for the breast surgeon before doing the mastectomy, obviously. The chance of a false negative result on frozen section has been reported to be as high as 15.4% in patient undergoing nipple sparing mastectomies. And most importantly, in patients with false negative results, the risk of local regional recurrence is reported to be 11.2% at five years, which is higher than that with traditional mastectomy. In 2012, Jensen and colleagues performed a nipple delay in a cohort of patients of whom several had grade two and grade three ptosis between seven and 21 days prior to nipple sparing mastectomy. And they described a modification of their delay technique in patients with nipple ptosis using the hemibatwing incision. And as you can see here, the incision, sorry, the skin excision pattern traveled halfway around the superior ulnar with a superlateral radial extension. At the time of delay, the inferior border of this pattern was incised and the NAC and surrounding skin was undermined, preserving the NAC profusion through the inferior and medial peri-ular dermis. This delay procedure allowed the basically safe removal of superior skin at the time of the mastectomy with nipple elevation to a more normal position with no reports of NAC necrosis. Systematic review of nipple delay procedures revealed a number of different techniques in incision with a range of one to six weeks prior to the mastectomy. In their review, no patients developed full thickness nipple necrosis with 8.9% developed partial necrosis. Of note, 6.9% had a positive sub-bary-ular biopsy and assisted in the excision of the nipple. And that's an important fact, right? Moving on to pre-mastectomy reduction mastopexy approach. This can be done in prophylactic and therapeutic mastectomy patients. And the approach is a little bit different. For the prophylactic group, the mastopexy reduction is done first and the nipple-sparing mastectomy with autologous reconstruction is completed later, typically a couple months. For the therapeutic mastectomy patient, a lot of the times the cancer has to be removed first, so the lumpectomy is done, along with the oncoplastic mastopexy kind of reduction and a contralateral balancing mastopexy reduction. And this is followed by nipple-sparing mastectomy and autologous reconstruction at least six to eight weeks later. Well, many oncologists published the largest study for this patient population, consisting of 61 patients undergoing pre-mastectomy reduction mastopexy, followed by autologous reconstruction. In their discussion, they talk about the benefits of this approach. And they say that the breast shape is determined by three components, the NAC position, skin envelope, and breast volume. And by doing this technique, it allows all three components to be altered in a manner that converts the patient to one in whom nipple-sparing mastectomy can be readily performed. And the complication rate after the second stage, they found to be 6.6% for nipple necrosis and the same for skin flap necrosis, which is fairly low compared to the current literature demonstrating the benefit of this approach. Here's an example on the left before surgery, center after the oncoplastic mastopexy and contralateral mastopexy for symmetry. And to the right, you can see the bilateral nipple-sparing mastectomy with immediate free flap reconstruction from the abdomen. Here's another example for a different paper. On the left, you can see the pre-op result with grade three ptosis. Centrally, you can see the result of their three months after the first stage breast reduction. And on the right, you can see six months result after the second stage nipple-sparing mastectomy with immediate free tissue transfer. This approach requires at least two separate surgical procedures to accomplish the mastectomy. And obviously, there's associated independent recovery time, anesthesia risk, hospitalization, and overall added cumulative expense. And some patients are not willing to go through this. And that's what brings us to our last technique, the post-mastectomy mastopexy, where the mastectomy is performed after the mastectomy and autologous reconstruction are completed. Of course, it does not delay the primary cancer resection, which is a plus. And the idea behind this approach is that the nipple could be moved based entirely on vascular contributions from the underlying perforated flap and that the full thickness parallel incision could be safely performed without necrosis of the nipple. Various skin pattern incisions have been proposed, ranging from Y-patterns, vertical leaves, and that depends on the degree of ptosis and where skin needs to be resected to achieve the desired modification of the breast shape. Here's an example. The skin around the reduced nipple area complex is depitalized on the left picture. Central photo shows the skin envelope is basically elevated over the flap as necessary and shape size is modified as desired. And on the right, you can see the closure is completed with the ideal NAC insert position. One of the largest studies out there is by a group in New Orleans. They examined 70 patients. The most common complication was minor incisional wound adhesions, and there are no cases of NAC necrosis following the secondary mastopexy. The authors eloquently talk about the benefits of this technique, and I think it's important to read that from here. Because of this robust NAC revascularization, it's possible to completely reposition the preserved NAC in a manner differing very little from a routine mastopexy. This completely frees the reconstructive surgeon to modify the breast shape, size, and NAC position at the time of the second stage revision without trepidation. It further removes the contraindication of even grade three ptosis from the selection criteria when consulting with patients who desire nipple-sparing mastectomy and are otherwise proper candidates. This powerful tool is a substantial advantage that any well-perfused flap reconstruction has over implant-based breast reconstruction. Here's the result. As you can see on the left, pre-op pictures, grade three ptosis patient. Centrally, you can see the patient after nipple-sparing mastectomy and deep flap reconstruction. And on the right, you can see the post-op result after mastopexy with improved breast shape and nipple position. Here's another example. The top row shows the patient preoperatively. The middle row shows the patient after having bilateral mastectomies and autologous breast reconstruction. And the bottom row shows the patient after having the second stage, the revision with the mastopexy. Great result. So in conclusion, several options for bilateral mastectomy and autologous breast construction in patients with tautic breasts exist, which is certainly a challenging group. As demand increases and the expectations become a lot higher, I do believe that surgeons should have all these approaches in their armamentarium when counseling this group of high-risk women with historically limited reconstructive options. At the end of the day, an individualist approach is followed for each patient based not only on patient's factors, but also on the breast surgeon and the plastic surgeon preferences. And definitely, larger multi-institutional studies are needed to compare these approaches and assess their oncological safety as well as patient satisfaction. Thank you. Thank you. Hello, everyone. I'm here to talk to you about how I like to think about defying gravity. So today in my practice after 19 years, I find patients are more interested in having a surgery with a reconstruction that is on par with their cosmetic surgery. So for example, this is a patient at three breast cosmetic procedures and has a fairly decent cosmetic result, but after a two-stage breast reconstruction and a little bit of fat grafting and exchange has a result that looks like this, which I think is actually a little bit better than the pseudo-totic nature of her right breast after augmentation. So nipple-sparing mastectomy is a fantastic surgery and works well on a patient with no ptosis. But what do we do for patients who have ptosis and significant glandular elements such as this? How do I think about staging these patients? Well, the first question I wanna know about is simply about their thoughts of nipple-sparing mastectomy. I think the nipple is the most important boardwalk piece of a novelty on a woman's breast, and I really wanna keep that. So my name is Brian Thornton. I'm the Director of Breast Restoration in Norton Healthcare. And this is how we consider staging these patients to optimize their results and defy gravity for nipple-sparing mastectomy with significant ptosis. My disclosures. So the goals of breast restoration for a patient like this with significant ptosis as I've talked to them about reconstruction is simply starting with nipple preservation. How important is the nipple preservation for them? Do we wanna save that? Obviously for a grade one, maybe two ptosis patients, that's a pretty straightforward procedure with significant ptosis and a large skin envelope that's difficult. The next question I wanna talk to them about is do they wanna decrease their cup size? It has been my experience that often small breasted patients wanna be bigger, but our larger breasted patients actually wanna be smaller, and we would need to do something with this excessive skin envelope if we want a smaller reconstruction. Obviously, all these patients are looking for no complications. We wanna go through an insurance approval pathway. And for me, these are the big key elements that I'm thinking about, support, support, support for every step that I do for these patients. And so typically we will offer them three surgical procedures in order to achieve these goals. We know that patients undergoing nipple-sparing mastectomy and think of their reconstruction as much more like them. They have a higher sexual as well as psychosocial wellbeing. And staging these patients has been shown in this publication to decrease the risk of complications. So there are two important elements that I talk to these patients about why this might be important, especially when we have large skin envelopes such as this is a patient with a BMI of 54 that we staged, who I did do immediate reconstruction on following our stage who had no complications. So the general framework for this is three surgeries, as I said. The first is a staging surgery of less than two hours of surgery, maybe a medial inferior pedicle. Medial pedicle is my preferred pedicle. But if they have an early stage cancer undergoing a simultaneous lumpectomy, that lumpectomy is gonna dictate the blood supply that remains intact to the nipple. They may undergo chemotherapy and have some delay, but this is the first time I'm thinking about support. Roughly two months later without chemotherapy, we're gonna undergo completion mastectomy with pre-pectoral expander placement. Typically we'll use those IMF incisions we created with the first stage to access the breast to do the mastectomy and place the expander. And again, I'm thinking about support. And then finally exchange, taking out their expander, putting in their implant. Typically we'll also wanna do some fat grafting. A lot of these patients have axillary fullness. It's a great access point to be able to get fat from or their abdomen or thighs. And in particular, I really don't wanna de-support when we take out the expander and put in the implant. So what am I thinking about in the first stage of support? Something I refer to as foundational support, but it's really just reestablishing the inframammary fold ligament that is removed during the mastectomy. So there's a patient undergoing Weiss pattern mastectomy. We can see how much that abdominal wall skins, but I like to run a 3-0 Stratafix to reestablish that. And you can see how less of a travel we'll see. This will often display itself when you see patients under augmentation or reconstruction where their implants are delivering below the inframammary fold as they're really kind of creating a space between scarpa and campers fascia. So I think it's really important in this first stage or at any stage to really reestablish the continuity of the inframammary fold ligament. And this is my preferred way of doing that. So we first want to go mastopexy reduction and to do foundational support. And so in this patient, that's what's happened with her. She's had a limited amount of tissue removed from her breast, but it's really about repositioning the nipples. So you can see roughly 305 grams from the right breast and less volume on the left breast. And now she's ready after staging with her mastopexy in order to go second stage, which for me will be a pre-practical two-stage device. I do like dermis again for about supporting mechanisms. I'm really thinking about reestablishing the superficial fascial system in patients and pre-practical breast reconstruction. I use dermis to be able to do that. It's a timely time to do it with the expander. It doesn't matter with the expander, which is sewn to them, but I'm trying to set the stage with their implant to follow. So here's the same patient. Now she's undergone her mastectomy with expander placement and expansion. She has roughly 510 CCs in her expanders. And now we're ready to talk about the third step of surgery. So again, third step of surgery for me is do they need axillary tailoring in order to make the breast look a little better? Again, maybe more support. This will be foundational support or inframammary fold, ligament reconstruction if necessary. I definitely, I think fat grafting is important, especially in the cleavage plane, if nothing else for these patients, to reestablish a nicer cleavage plane in the superior pole as well. And again, it's really about not de-supporting the breast implant. So I really try to limit the capsulotomy. No capsulotomy is the goal for these patients. Unlike our submuscular days where a capsulotomy was done, the pectoralis major is that bonded to the skin or healed to the skin really prevented drifting of the skin envelope. I think capsulotomy in the prefectural patients is gonna guarantee a high risk for a potential third surgery because you've really destabilized or unsupported the breast. So this is this patient now. We did a 635 CC moderate high boost implant as well as some fat grafting to both sides. And I think she has a very overall aesthetic result in three-step surgery to do that. So something to think about. So I do tell these patients that their first intervention, you're gonna be looking at three surgical procedures to save the nipple, to have less risk for complications. This is the general framework, but even for patients who don't wanna keep their nipple but are interested in nipple reconstruction and tattooing, I do talk to them about the fact that can be three or more procedures. And of course, nipple reconstruction is not guaranteed to maintain projection of the nipple. There won't be sensation in the skin island that I recreated with. And all tattoos will fade over a five to 10 year timeframe, especially in a lighter skin patient compared to a darker tattoo for a darker patient. I think where to start for this, if you're interested as in patients that are high risk genetics, who don't have cancer, you can really learn how to work with your breast surgeons to be able to do this. And then as time moves on, evolve into doing this with cancer patients, which is commonly done for us. So again, my name is Brian Thorne. I'm Director of Breast Restoration for Norton Healthcare. And this is the way we defy gravity for our totic patients. Thank you so much for your attention. Hi, everyone. This is Paige Myers with the University of Michigan. Thank you for this opportunity to discuss immediate reconstruction of the totic breast, considerations in the setting of skin sparing mastectomy. I have no financial disclosures. While this panel is discussing strategies for reconstruction of the totic breast and nipple sparing mastectomies, sometimes it's just not possible to keep the nipple. As reconstructive surgeons, we need to be prepared to perform an aesthetically pleasing and safe reconstruction in women with totic breasts who are not candidates for nipple sparing mastectomies. Breast reconstruction procedures continue to be on the rise with nearly 160,000 breast reconstructive procedures performed in 2023 alone. Additionally, a significant proportion of our society continues to be overweight and obese as estimated by the NIH. Nearly 30% of women can be categorized as overweight, over 40% of obese, with nearly 12% approaching that severe obesity category. Additionally, there are several cancers associated with overweight and obesity, including breast cancer in the post-menopausal women. Breast ptosis refers to the position of the nipple relative to the inframammary fold. A high-grade ptosis, or a low position of the nipple, can present reconstructive challenges, especially in the setting of macromastia and obesity. We are all familiar with this relationship of macromastia, or large breasts, being associated with obesity, and then the large, heavy breasts, oftentimes being associated with higher grades of ptosis. These characteristics can present a reconstructive challenge precluding patients from being a safe candidate for nipple-sparing mastectomies. Additionally, a lot of breast reconstruction today is being performed in the pre-pectoral plane, which certainly has advantages, but has disadvantages of often requiring a cellular dermal matrix, which can be very costly. So today, we will talk about a technique which is the WISE pattern mastectomy, where the inferior mastectomy flap is deepothelialized and used as an autoderm sling in the pre-pectoral implant to replace the need for ADM. There are several benefits to this technique. The WISE pattern mastectomy allows the breast to be reshaped with the future NAC position at the point of maximal projection of the breast. This is in contrast to the flattening that is sometimes seen with a transverse incision mastectomy. The inferior autoderm avoids the use of ADM with its associated complications and cost. This technique affords the breast surgeon a very wide exposure for access to the breast as well as the axilla, and we found that there's a similar OR time and complication profile between the techniques. My technique begins in the preoperative area with marking. I mark the traditional markings of the inframammary fold as well as the center of the breast and the breast meridian, as well as a modified WISE pattern incision. You can see the green markings here are what the breast surgeons use to access the breast and sometimes the axilla. The top of the WISE pattern is often designed at the level of the top of the areola. This is just another marking of a patient with large tautic breasts. You can see here the purple area is what gets removed with the breast for the mastectomy, and then the markings on this orange area are what gets diapothelialized as an autoderm sling to cover the tissue expander. Here is the patient immediately following the mastectomy. You can see the superior and inferior mastectomy flaps as well as the pectoralis muscle on the chest wall. Next, the inferior mastectomy flap is diapothelialized. The tissue expander is secured in the preflectoral plane, and the autoderm flap is secured to cover the implant. If the flap is long enough, it can be secured directly to the pectoralis and the chest wall. Occasionally, it has to be secured to the underside of the superior mastectomy flap. I typically will use two ovacral sutures for this step, especially if it's secured to the underside of the superior mastectomy flap because those will eventually dissolve. The autoderm, again, is secured to cover the implant, and the Y's pattern incision is closed in the traditional fashion. A few pearls for this technique. I always use two drains for prefectural reconstruction. This is because alloderm as well as the autoderm flap can be seromogenic. The drains are placed several centimeters below the implant, so the autoderm flap is secured to the implant and the drains are placed several centimeters below the inframammary fold on the lateral chest wall. Like I mentioned, I mark the top of the Ys lower than the traditional Ys pattern, usually at the top of the areola. This is because I want to preserve as much mastectomy skin as possible, and the fact that I have to excise some in the case of poor vascularity. I always use peroxide saline mixture for irrigation for hemostasis. If there's a lot of redundant skin that I can't necessarily fill with the expander, or if there's just a very large space, I'll place a tegaderm bra to help keep things in place. In designing green angiographies, use if there's any question of mastectomy skin flap perfusion. I'll never leave the tissue expander totally flat. I always fill it with at least 50 or 100 cc's of air to help smooth out the edges and make the patient more comfortable. And then importantly, the height of the lower mastectomy flap, the distance of the autoderm, must be greater than the length of the vertical limbs to provide protection along the vertical limb in the case of any mastectomy flap necrosis we see here. This is a 79-year-old patient one month out from a right skin-sparing mastectomy, a sentinel lymph node biopsy, and local tissue rearrangement with the inferior mastectomy flap measuring 10 by 15 centimeters. She was filled with 50 cc's. She presented with mastectomy flap necrosis and some delayed wound healing at the T-junction here, which is very common. We took her immediately to the operating room for tabrinit. I was happy to find that there was actually a very healthy, soft tissue vascularized layer covering the implant. The implant was not actually exposed. So because of this, we were just able to re-advance the superior mastectomy flap and save her a complete washout of her expander. A few other cases, this technique is great for both implant and autologous reconstruction. In the autologous reconstruction patient, I like to use this in the setting in the case of delayed immediate reconstruction. So this is a 30-year-old patient with breast cancer. She underwent a left mastectomy, sentinel node biopsy, innerwise pattern mastectomy with autoderm, with the autoderm flap also measuring 10 by 15 centimeters. And the tissue expander eventually filled to 550 cc's of saline. She then underwent delayed left deep flap with a contralateral reduction and fat grafting. And you can see, as I had mentioned, the future nipple position is at the point of maximal projection of her left side. It matches very nicely with the new nipple position of her right reduced breast. Here's just some more pre and post-op photos with the technique that I had mentioned. This is also great in the setting of two-staged implant-based reconstruction. This is a 65-year-old female, also with left breast cancer. She underwent bilateral mastectomy with 800 cc tissue expander placement and local tissue arrangement with a 20 by 15 centimeter inferior mastectomy flap autoderm. She completed adjuvant radiation therapy and then underwent silicone implant placement with 600 cc implants and fat grafting. She has a very nice result. And we hypothesize that this autoderm flap is actually protective against radiation changes, although this study is still undergoing. Here is her pre and a year post-op photos. We wanted to make sure this technique was both safe and effective for breast reconstruction and our patient population. So we looked at a three-year study looking at breast reconstruction following mastectomy. This encompassed female patients and we ultimately ended up comparing 288 patients. A few findings in our demographics, not surprisingly, patients with higher BMI received WISE pattern incision reconstruction. Additionally, patients that underwent WISE pattern incision had greater degree of ptosis. Importantly, that we found that there was no difference in OR time, which is one of the criticisms of this technique, given how long it may take to deepothelialize the inferior mastectomy flap. Additionally, we found that there was a lower implant cost with the WISE pattern incision as there was oftentimes not alloderm used in the situation. We compared the complication profile of the WISE pattern incision to the non-WISE pattern incision. While on univariate analysis, we found that there was a higher rate of seroma as well as delayed wound healing in the WISE pattern incision, this did not hold in our multivariate analysis. In fact, incision type was not a significant indicator of overall complications on multivariate analysis. In conclusion, a WISE pattern mastectomy with an autoderm sign is a safe, efficient, and cost-conscious way to reconstruct large tautic breasts in the setting of immediate reconstruction. Thank you for your time and attention. Dr. Sorotos Hello, everybody. I am Dr. Sorotos. I am from Rome. I'm moderating this very interesting session in defined gravity strategies for nipple-sparing mastectomy with significant doses. We've got some great presentations from great panelists. It's a great honor for me to be moderating those panelists. So we'll just jump into the discussion and discuss the presentations. And I would like to thank all of you for participating and start with the presentation of Dr. Kaujanis. He talked to us about how we, about his presentation was about defined gravity strategies for autologous breast reconstruction following nipple-sparing mastectomy in patients with significant doses. So I would like to ask the other panelists if they have some questions for the presentation of Dr. Kaujanis. I do. I want to say thanks for your great presentation. I loved your thoughtfulness on everything. The delayed mastopexy after deep flap that you showed, have you ever tried that with implant-based reconstruction or is it just something that you've limited to flap reconstruction? I have done it for implants as well. And I think it does work for implants as well as long as you don't have to move the nipple too far. I mean, it wasn't super tautic breast, but I think maybe two, three centimeters, I think you can do it, as long as there's some tissue around that. Now, of course it depends on the patient as well. I think has to do with patient characteristics and if they have any other comorbidities and things like that. So I'm not very aggressive for candidates, but for healthy patients, I think a little more aggressive doing that. I agree. I've done it a few times, but you have to completely delaminate the skin flaps from the capsule in order to get any movement at all. Kind of like you were showing lifting up the whole mastectomy skin flap off of your deep flap to make it work. What's the upper size limit that you have for the flaps? You said, you mentioned if they're too large, you stage them, but I didn't quite capture what that size limit is. Is it just a feel thing or is it a pure number that you have in mind? Typically for me, I would say anywhere between 600 and 800. If I feel that the patient's abdomen will be way higher than that, then I stage it because I did have some bad outcomes with big flaps in terms of my skin necrosis. So if I'm at those numbers, I just felt that it's better to stage. You just put a tissue expander. Honestly, sometimes now what I do, I just throw a tissue expander very quickly, like taking like 20, 30 minutes to do that. And I stage kind of immediate delay where I bring the patient back two weeks later or something, make sure the mastectomy is, make it through the initial stage and then take the expanders out. I don't have to do a capsulectomy or anything else. It's literally just clean the pocket a little bit and just do the flaps. So I think that's a way for some of those patients with larger flaps. And the immediate reconstruction for me, immediate deep reconstruction for me, it's better for patients who don't, if the weight of your mastectomy, it's gonna be the same or a little bit smaller, you know, when you put the flap in. If you start getting into much higher weights, I think it's better to stage it, honestly. Yeah. Okay. I have a question as well for you. You, in one of your cases, so where do you put your skin islands to monitor your flaps or how do you monitor your flaps? Or, because usually when we do skin-sparing mastectomies, we either leave a small crescent of a skin island above the nipple, or if our general surgeon is okay, we just leave it on the inframammary fold. Do you place any skin island to monitor your flaps or you use other techniques? Typically I do. Some of my partners bury their flaps sometimes with cooked Dopplers, but I typically leave even just a small paddle. It's not so much to monitor the signal through the paddle because sometimes I monitor through the mastectomy skin flap, but it's more for my reassurance to be able to see the flap, and make sure it doesn't get congested because that's a clinical diagnosis most of the time. For a skin-sparing mastectomy, I would just leave it where the incision is, whatever that, you know, around the nipple that was, you know, nipple or a compass that was removed. For nipple sparing, depends where the incision is, right? So sometimes I do a vertical incision, sometimes I do an inframammary incision, and I would just leave it just below the nipple complex at the vertical there. Sometimes I do Weiss patterns. So again, I would just leave it at the vertical or I leave almost like a triangular skin paddle there, and I come back later and I basically elevate the flaps and just close it and do a lift at the same time. Sort of post-mastectomy mastopexy type of situation. I guess to go back to what Dr. LeBlanc says, when you do autologous reconstruction and you have problems with the mastectomy flaps, you feel a bit safer to deal with it because you have a free flap underneath. So it makes things easier to deal with. Okay, any other questions for Dr. Kowaljanis? Okay, so perfect. We can move on to the presentation of Dr. Moussarafa. He spoke about immediate direct implant breast reconstruction with concurrent nipple sparing mastectomy, mastopexy. And I really enjoyed your presentation. I like the whole algorithm about the base speed and the maximum nipple to inframammary fold distance. And then you say that smokers, I will just ask the question directly, I'm sorry. You said that smokers are not great candidates for this kind of surgery. And how do you deal with smokers? Do you ask them to stop? Is it enough? Or you just change your plan? Yeah, we do have a protocol. We do ask them to stop and then we will test them. We'll do a cottony urine test, which is a by-product of nicotine that typically stays in their system for about three weeks. And we reassure them that we're not trying to catch them or condemn them for smoking. It really is about their safety and about reducing the chance of complications. And so for anybody who is an active or current smoker that's interested, we'll ask them to quit a minimum of three weeks before surgery and continue to avoid nicotine. And it's, again, it's not just cigarettes. It's now with the advent of vapes and nicotine gum, and there's all these nicotine substitute patches and things. So they do have to stop in the absence of a nicotine substitute. And we test them for that preoperatively. Okay, I have another question afterwards. Can I ask a follow-up question on that? Here in Colorado, we have a lot of patients who are on THC, whether that's edibles or smoking. And we've done some kind of data-based studies showing that it does increase the risk of complications for breast constriction. Do you see any of those patients and what's your approach? Yeah, that's something I think we really need to investigate further because recreational THC is legal in Arizona as well, just like it is in Colorado. And particularly in the cancer patient population, a number of these patients are using it to deal with post chemotherapy nausea, pain control, or really just for mental health reasons. And so to me, it's clear there are some benefits to patients. I don't think they're using this in the way that people used it when I was a kid. It does have real health benefits to certain patients. I personally have not experienced any complications as it relates to blood flow or seen an increase in flap loss. I can't quantify exactly how many patients that we see that admit to using THC, but the number is probably higher than the ones that check the box on our intake forms. And I haven't seen any indication that it's a contraindication to doing a nipple sparing procedure. Cool. Okay, any other questions? We definitely need to study that more. And I appreciate those that are doing that because it's becoming very, very commonplace. Yeah. Dr. LeBlanc, you have a question for? I do. Tamara, I'm a huge fan of your paper. It was very inspirational for me and I've been using your technique for several years now. So thank you very much for that. Have you expanded your parameters since the original article came out in terms of your nipple to fold? I remember you said that you wouldn't attempt it on people with a nipple to fold of greater than 15 centimeters. Have you pushed the envelope at all on that? I have not pushed the envelope on that. I have pushed the envelope on implant size a bit. And as I think you pointed out as well in your talk, which was excellent, that's so dependent on the breast surgeon. And so I do think the 14, initially I actually thought it was about 12 centimeters. So to answer the question properly, I did expand it to where I am now, which is 14 centimeters. I haven't tried it on a patient with a nipple to fold distance over 14 centimeters. It just really, even with the longer nipple to fold distances, the nipples look kind of questionable. And I showed, I think a patient or two where you get a little bit of partial necrosis of the nipple areolar complex. And those always worry you because of the fact that, really underneath that is just the ADM. So no, I haven't gone beyond 14 centimeters, but I have done some pretty substantial volume increases with the right breast surgeon if the mastectomy flaps look favorable. Great. I've got wonderful breast surgeons. I'm spoiled rotten by them, but I've done one. I was looking at my measurements just to see what my biggest one was. And it was 19 centimeters. Wow. And the implant size was a 745 direct implant. And she had partial areolar loss as you would expect, but it worked and everything healed in. So I kind of got lucky on it, I think. No, that's great to know. I'm sure that I'll see a patient that, and I may test that eventually, but I've been kind of chicken so far. My follow-up question is, you said you use the entire width of the IMF as your pedicle. Do you ever find that the breasts look boxy because you're leaving too much medial and lateral? And have you ever, like I take out a little dog ear triangle at the far medial and far lateral end to prevent that kind of boxiness. And I don't think it compromises the flap as much as you think. But I was just curious if you've ever done that. Yeah, I have. I prefer to save that for a secondary procedure. As you know, probably about 70% of my patients that have immediate direct to implant reconstruction have at least one session of fat grafting. And I don't do a lot of fat grafting at the first stage. I just am always concerned about grafting into a mastectomy, into the subcutaneous plane in a mastectomy skin flap. So I talk to them about it, and that's a great point. I do tell them that, especially the patients with really broad chest and a wide breast, that they'll look a little flat in the lower pole. And at the time of the secondary procedure, if we're gonna do fat grafting, then I'll excise that excess skin then. But I have done it acutely as well. It really just depends on what the nipple looks like. If, you know, Dr. Vasquez used to tell us there's only one shade of perfect. And if it's that shade of perfect, then I think you can be a little bit more aggressive. If it's not that shade of perfect, then I just leave it alone. Great. Will you expound on your antibiotic bead use? Do you, are you using those on every single implant-based reconstruction or just these more extensive scary ones? Yeah, I'm using it on every implant reconstruction. So this is an off-label use for this product, but I will tell you that the data on implant infections and immediate reconstruction really shocked me. It's quite a bit higher than what I would have guessed it was. And if I'm being honest, when I really look back and audit my own practice, I probably fall in line with the national numbers. And so implant infections and immediate direct implant reconstruction can are anywhere between eight and 20%. And it's obviously, it's hugely consequential because most of those patients require implant removal. And so every implant reconstruction I do, whether I'm doing a modified mastopexy closure, whether I'm doing a nipple sparing, I will use antibiotic beads. I use, the product is called Stimulan, and they have a 5cc and 10cc product. And I, for the 10cc product for bilaterals, I add one gram of vancomycin and 240 milligrams of genomycin if they don't have allergies. And I just distribute the beads evenly in each pocket. And the last presentation I saw on it was a local surgeon here in Arizona. She's been using it for three years and she brought her infection rate down from 12% to one and a half percent. And so I think as more and more data comes out about this, it's gonna become something that is really utilized. And when I think about it, why not? It's not a terribly expensive product. I think it's around $800 or something or $900 for the 10 cc stimulant and then plus the cost of the antibiotics. So it's hard and they're gone in six weeks. So some really thin patients will sometimes feel the little pellets. They have different size, the template that you use to make the beads have different sizes and I just use the smallest ones. But by six weeks, they're gone. And I've been using it for about a year now and I've definitely seen a reduction and even that kind of worrisome erythema that you put them on prolonged antibiotics for and then it clears up, even the incidence of that has gone down. Are they serogenic at all? Do you notice an increase in your drain outputs or anything like that? I haven't noticed an increase in the drain output, but sometimes the drain output gets a little milky as they dissolve. And so, as I mentioned, I always leave my drains in for at least two weeks when I use ADM, regardless of their output. And a lot of times in that second week, the patients get a little bit concerned because they see any viscosity in their fluid and they assume pus. And so I just tell them, I said, you may notice that the output from your drains will start to get a little bit milky. That's just related to the antibiotic beads. But I haven't seen an increase in drain output or an increase in duration of my drain since I started using it now. Yeah, great. Thank you. Yeah. Let's see, I'll expand that a little bit. I started using them too. It's been several months I've been using them and it's very easy to use them because now the scrub techs, they know, they're prepared even before I get into a case because I have a different table on my part and they're there and use the smallest one. One of the things I think that I was told, at least from the companies, that you have to use small number. You don't want to put like a thousand beads in there. You just want to use small numbers in different areas. If you put a lot, then there's increased risk of seromas. So I don't use large amounts of that. I don't have too much data to share because I've only been using them for the last few months. But I think, I agree that it's something that we're going to see a lot more over the next two years. And if it will decrease even like two or 3% spectral rate, that's a huge number. Okay. So we move to the next presentation by Dr. LeBlanc about superiorly based mass effects with direct implant perpetual breast reconstruction. And I actually have a question for both you and Dr. Mozarafa. I like your algorithm about the six centimeters, how much you have to move the nipple and which pedicle to use. And then, and most of all, I like your mastectomy flaps. Some of your pictures are perfect. And I think just a general question about all of you is how do you deal with your breast surgeons? Because it's very important in this type of surgery, the communication between plastic surgeons and general surgeons. And I don't know how to know, like if you do the incisions for them, some surgeons like to prefer the mastectomy flaps. Do you do any of these or it's just good communication and good collaboration? I'll start if that's okay. I've cultivated my relationship with the breast surgeons very carefully and I tend not to work very much with the ones that don't routinely leave me good flaps or are not interested in improving their flaps. That's the big kicker for me. But the ones that are interested in watching the spy and looking at their results, then it becomes a communication of nuances and starting to understand that the breast borders, where the breast ends. So I mark all my patients the day prior to the surgery. And I very clearly delineate all of the borders of the breast for them so that they know where I think breast tissue is ending. Now they have the right to go beyond those borders if they disagree with me, but most of the time they're like, you're spot on. And I'm like, thanks. And then looking at the mammograms with them and kind of teaching them that there's a taper to the thickness of the fat from the nipple to the chest wall and leaving me more thicker superior pole instead of chasing a universal thin flap all the way up to the clavicle. Now they're leaving me more healthy, superior mastectomy flaps because they are not skeletonizing that layer. And then protecting the cleavage, protecting the lateral breast border, not going all the way to the anterior border of the latissimus and not blowing through the inframammary fold. I think Tamar, Dr. Marshalfer, you had a lovely demonstration of that shiftiness of the IMF and how you anchor it. And just working with the breast surgeons when they're starting to work with you, scrubbing in with them, telling them what's important to you is super helpful, especially if you're new in the relationship with them. And if they're willing to improve, then your results are gonna improve because of that teamwork. Yeah, I can't take credit for the anchoring of the IMF. That wasn't me, but I- Oh, I'm sorry. I thought that was you. Brian. Yeah. Maybe it was Brian. I'm so sorry. Yeah, no, that's okay. I thought that was you. So yeah, Brian showed that great in his video. Yeah, no, I thought that was fantastic. And I completely agree with everything you said. I have enough gray hair now where I can be a little bit more selective in who I'll work with. In Phoenix anyway, what has really benefited me is that the breast surgeons themselves are starting to, we don't have to fight this battle with them because Steve Sigalov's wife, Noemi Sigalov, is in practice here in Scottsdale. And she, at their local meetings, talks to them about how important it is to preserve that flap thickness and how oncologically sound that flap thickness is. And so there's been kind of a revolution here in Scottsdale that I've benefited from. And I have longstanding relationships with my breast surgeons as well. But what I actually, and this is not very time efficient, but I'm actually there from start to finish when I do this mastopexy procedure. So I will actually do the deeper delization because I feel like we're just a little bit better at it. And when I do that, we're just a little bit better at it. And when I have tried to let the breast surgeon deeper delialize, even in my presence, there's a lot of holes. And so I do the markings in the pre-op area. Then I will deeper delialize and make the incisions. And then I can step out and either, depending on where I'm working, get some work done in my office or have a long breakfast and then go back and finish. So these are not terribly time efficient procedures for me yet. There are probably one or two surgeons that I work with that I'd be comfortable letting them do that just with my markings, but I haven't gotten there yet. Okay. And then another question I have for you. Some of the patients you had didn't have such a, at least in my eyes, a great ptosis and you still, you did mastectomy nevertheless. And they had great results in post-op. So I really liked them. So sometimes in our practice, when we have moderate ptosis, we, in Italy, we have a special ADM we use that wraps around the whole implant. And then we have some retraction and we might get some, we get good results with like the retraction of the mastectomy skin. But some of the cases you showed, like looking at them pre-op, I would say, okay, maybe one could try a nipple sparing mastectomy and you did the mastopexy and it was a great result. And I would like to know, how do you deal with that? Like, how do you decide how much, when you're going to do a mastectomy or a nipple sparing mastectomy? So the algorithm, you know, if they're not complaining of their mild ptosis, I don't talk them into anything. So my algorithm is, they have to be, they have to bring it up. They have to say, I would love to have a more lifted appearance to my breast. And then we go down the discussion pathway of, well, there's a possibility to do the mastopexy at the time, but it's not guaranteed. And if I can't do it then, then I might be able to do it later and do a delayed mastopexy over the implant-based reconstruction. So kind of like Dr. Kazanis was talking about earlier over the deep flap. But the algorithm is really patient driven. They have to be complaining of their ptosis. And if they're not, I think a direct to implant nipple sparing with their tautic nipple position, you can get mild correction, like you said, with the ADM wraps and the repositioning of that skin flap as you let them heal. But if they're more than a grade two ptosis, then I'm usually talking to them about doing the lift if they have complained about their ptosis. Yeah. And correct me if I'm mistaken, you were using some external medication, like not compressive, but some kind of medication. And I've noticed that Dr. Mosorafa said he doesn't use any of that. I know that it's a surgeon's preference. Some people will want to stabilize the ADM and make it integrate faster. I don't know, I'm just thinking of it integrates faster. So what's your opinion on that? It definitely cuts down on drain output and time of drains. So, and to me that equates to incorporation perhaps of the ADM or at least stabilization of the pocket. So I think it really, and it acts a little bit like a governor for them when they are in the recovery phase, because what he's referring to is I put a Tegaderm bra over the breasts and that stays on until the drainage tubes come out. So it's clear at see-through, we can monitor the flaps through it, but they can shower over the top of it. And there it's a little more humane than other versions, but it's extremely inexpensive. It's not like Provena or some battery operated thing that they have to carry around. So it's convenient for the patient, which is why I like it. But it is a, I think it really shut down drain output for me. Normally I would put two drains in on a pre-pectoral ADM wrap but since I started using the Tegaderm bra, I only put one drain in up the lateral gutter and over the superior pole. And it may have more to do with how I anchor in the ADM that decreases their fluid production, but I see very few seromas and drains come out for me on low BMI patients at about 10 days, high BMI patients almost always by 14 days. So rarely am I leaving the drains in longer than two weeks. So it's doing something. Yeah, of course. Okay, any other comments, questions? That was a great presentation. A couple of questions. Do you have an upper limit for your implants or? No. I've gone all the way to 770 direct implant with the mastopexy. Cool. And if you do see like full thickness nipple complex necrosis, do you take it back? Do you downsize the implant? Do you just cut it out? How do you address that? It depends on what's, you know, if the necrosis is full thickness through, you know, that whole superior pedicle that I've done, which it usually is when the nipple dies completely, then I'm cutting out on a vertical limb and just getting rid of the nipple complex. And if there is no significant amount of infection or concern that the implant space has been contaminated, I'm usually just irrigating it out. Most of the ADM at that point, usually we're two or three weeks in, and at least the medial and lateral ADM is already starting to stick. The stuff right underneath the necrotic tissue obviously didn't become adherent. So you definitely have a little seroma pocket there that you have to place a drain into again. But usually I can just close up. Now, if they've become infected, then you've got to undo the whole thing, which is disaster, which I think I showed in my talk. So only had a few of those, thankfully, so. But it's definitely risky. I try to sit on those partial nipple necrosis. And I don't know, Dr. Musharraf, have you experienced that with that little bit of the areola kind of sloughing? I kind of sit on those and see how they do. Whereas if it's on the vertical incision on those mastopexies, if I'm having any wound breakdown or T-junction breakdown, I don't sit on those very long because I just don't have as much tissue underneath that part of the incision to protect the implant. Yeah, I agree. It's the opposite for me because I'm doing an inferior pedicle. So the T-junction breakdown, I don't worry about at all. Those, I just treat conservatively. And I'm fascinated by nipples. They always turn out better than you think they're going to do. So I've gotten very, very slow to act when it comes to that. And I think I showed one patient that I'm a firm believer in hyperbaric oxygen. I think it really does make a difference. So anybody that has any ischemia in any part of their mastectomy flaps, including the nipple areolar complex, I will send for HBO. And I have a good relationship with a place in town here that gets them in right away. But yeah, I agree with you. I do tend to sit on them a little more than I would with a typical mastectomy flap breakdown directly over ADM, just because I have a little bit of a security blanket with that inferior pedicle. I have also, I'm sorry. I was going to agree with you on hyperbaric oxygen. I recently have a new freestanding HBOT center near me and they've been a huge help. So it's been very nice to have them. I've got a question for you too. I loved how you outlined with the superior pedicle technique, which I've tried. And I always struggle with that buckling or the kind of tethering that you get. And I love how you sort of identified the position of the nipple relative to the key hole as being really the key factor. And you showed in one of your slides, a picture of that dermal release that you'll do at the corners. Is that, what you showed in that slide, is that pretty typical of how extensive a release you need for a nipple that is sort of at the bottom of the key hole? Or do you sometimes have to do more than that? I think that's pretty typical. I've done it with the nipple still attached at the 12 o'clock position and the vertical limb tailor-tucked with staples and kind of teased up the dermis and releasing it little by little by little by little until I feel like I can get the nipple closed. And then I undo that tailor-tucking to see how much release I actually had to do to get it closed until I found that that was a pretty typical cut that I would have to do. So kind of from nine o'clock on the key hole and three o'clock on the key hole down past the corners, just a centimeter or so, is usually all I have to do. And that's enough to release it to get it to close without buckling. Yeah, that's great. That's really helpful. And now we're gonna move on to discuss the presentation of Dr. Myers. Thank you very much for your presentation, Dr. Myers. You spoke about immediate reconstruction of the ptotic breast and the considerations for skin-sparing mastectomy, mainly in women with big breasts. So I have some questions. First of all, I would like to know if you use ADMs at all, you don't use ADMs at all, or do you sometimes use them if you have a big volume to cover in terms of the expander? I typically don't use ADM when we have the inferior autoderm. I think it provides many of the same benefits, but it's actually vascularized tissue. So it's able to cover the implant. It gives it a little bit support in that inferior pole as well as kind of protect that vertical incision like I mentioned in my PowerPoint. There aren't, we're currently looking at kind of the long-term results comparing the autoderm to the ADM in terms of some of the other benefits that ADM can offer like capsular contracture. And so I'm hoping to get some more data about that in the future as well as the resistance to radiation. Okay. And when it comes to your reconstructive steps, is the expander your first choice always, or do you sometimes try a direct reconstruction with either the DFLAP or an implant? That's a really great question. Unfortunately, I don't do a lot of direct to implant reconstruction. I think the ideal candidates for that are really small-breasted women, thin and early stage cancer, as well as having a reliable mastectomy flap. And so I typically tend to prefer two-stage reconstruction in all aspects. For implant-based reconstruction, this involves a pre-pectoral tissue expander. I fill my expanders with air so they're a little bit lighter on the skin compared to some of the heavier implant materials. I also think that has a lot of benefits in the autologous reconstruction as well. Okay. And I saw in your presentation compared to the other panelists, you're dealing with very big volumes, breast volumes. So when it comes to the nipple areola complex, is it an oncologic decision not to keep it, or sometimes you actually make this decision because of the big breast that you have to deal with? A lot of the times in women with larger breast size, as well as higher BMIs, the decision is simply logistic that the nipple areola complex would be unlikely to survive or be wildly out of position if we decided to save it. And so I often talk to my patients about the overall breast shape will be improved by the use of the WISE pattern mastectomy flap with the autoderm, and then get into a discussion of nipple reconstruction techniques. We do a lot of three-dimensional tattooing in our community, and I think those have really pretty results that women are very happy with. I agree with that. And do you have to deal with many patients that are smokers, active smokers, and how do you deal with them? Do you ask them to stop smoking, or do you modify your technique? That's a great question. We thankfully don't have too many smokers, but certainly they do come along. And I think this is where the patient-centered decision making of breast reconstruction really comes into play. I will offer immediate reconstruction for women that are actively smoking. We talk about the risks. I provide smoking cessation resources, but will often give them a try. In my presentation, I mentioned one of the modifications to the WISE pattern design is I really just make the top of that WISE pattern just around the areola. So this preserves as much mastectomy skin as I have, anticipating that I will likely have to debride some, especially in women that are smokers. So by keeping them as much of the mastectomy skin that as I can, I'll use the indesigning green angiography, and usually we'll have to take some skin off, but by preserving as much, I have some to work with. I also give them a one shot and done. Usually, for people that get infections or other reasons for tissue expander complications, we can usually wash it out and replace it. But if there's any complications in women with active smokers, I say we remove it, you go flat until we can get off the nicotine. I think that's WISE to do. Okay, so thank you very much for answering those questions.

breast reconstruction

nipple-sparing mastectomies

inferior pedicle technique

superiorly-based mastopexies

pre-pectoral spaces

autologous reconstruction

WISE pattern mastectomies

autoderm slings

mastectomy flap viability

patient-specific approaches

preoperative planning

nicotine impact

collaboration with surgeons

customized techniques