This video will focus on the surgical technique and pearls for single-stage, skin-only mastopexy with nipple-sparing mastectomy and direct implant reconstruction. Standard preoperative mastopexy markings are made with the patient in the upright position. These include sternal notch, midline, breast meridians, inframammary fold, proposed nipple location, and proposed mastopexy pattern markings. The decision to commit to the mastopexy incision pattern and to de-epithelialize prior to mastectomy is surgeon preference. Some may prefer to wait until after mastectomy is complete and size replacement and tailor tacking can be performed. In this patient, a circumvertical mastopexy pattern is planned, therefore, a vertical infrarial or incision is marked for the nipple-sparing mastectomy. The mastopexy skin incision pattern utilized depends on the degrees of nipple-aerial or complex ptosis and vertical and horizontal skin excess, most commonly utilized in our practice are circumvertical or Y's pattern. In the circumvertical mastopexy, the mastectomy incision is designed as a vertical infrarial or incision, maintaining the nipple-aerial or complex on a superiorly based dermal pedicle. Planned nipple elevation should not exceed 4 centimeters as movements greater than this will likely require back cuts in the dermal pedicle to facilitate movement, thus potentially compromising the nipple-aerial or complex blood supply. In the Y's pattern, the mastectomy skin incision is designed superior to the nipple-aerial or complex maintaining its blood supply on a broad, inferiorly based dermal pedicle. Although not commonly used in our practice, authors have demonstrated nipple movements of up to 16 centimeters with this technique. After mastectomy is performed, the skin-flat viability can either be evaluated clinically or with perfusion imaging devices. Any non-viable tissue should be removed. If the nipple-aerial or complex is deemed non-viable, it can be removed and replaced as a free nipple graft. Therefore, it's critical to always consent for this. A tissue expander can be placed instead of a permanent implant and, if necessary, to optimize skin and nipple-aerial or complex perfusion. After evaluation and confirmation of healthy mastectomy skin flaps and nipple-aerial or complexes, a sizer is placed in the mastectomy pocket, taking into consideration the breast base width and mastectomy specimen weight. Our practice has transitioned to nearly 100% pre-pectoral reconstructions, owing to the benefits in pain control, animation deformity, and ease for transition to autologous reconstruction. In this case, after the sizer was placed, tailor tacking was performed, and the new nipple-aerial or complex position and mastospexy skin pattern marked with the patient in the upright position. After returning to the supine position, the circumvertical pattern was then incised through epidermis and deepithelialized, evaluating for healthy dermal bleeding. The sizer was then replaced with a permanent implant after irrigating with betadine. Soft tissue support for the implant can vary widely. Early in our practice with pre-pectoral reconstruction, we were utilizing ADM as an inferior gutter to support the implant, as shown in the photo on the left. We then transitioned to total anterior implant coverage with ADM. More recently, we have transitioned to the construct shown in the middle, in which synthetic mesh, which in our practice is P4HB, covers the anterior lower pole and posterior aspect of the implant, and ADM covers the anterior upper pole. The synthetic mesh and ADM are sutured to each other with two oviclal sutures to completely encapsulate the implant. The implant ADM mesh construct is secured to the chest wall at multiple points with two OPDS suture. A 15 French strain is placed, the nipple areolar complex is inset, and vertical limbs close with absorbable suture. With our transition to exclusively using smooth, round implants in our practice, we've transitioned to using a combination of P4HB and ADM for device coverage and direct implant reconstruction for multiple reasons. First, we have noted that the synthetic mesh along the lower pole and posterior surface of the implant helps maintain the position of the implant on the chest wall and provides enhanced stability at the IMF compared to ADM. Many of our patients undergoing immediate implant-based breast reconstruction with round implants will present postoperatively with expected upper pole contour deformities that are amenable to fat grafting. Since the soft tissue left behind after P4HB placement is known to be two to four times stronger than native tissue, we've unsurprisingly found that fat grafting into this tissue can be more difficult. Therefore, we place the softer and thicker ADM in the upper pole for a softer feel and a more natural appearance as it camouflages the upper pole implant surface and rippling. The ADM also provides a better substrate for future fat grafting, which is most necessary in the upper poles. This is the final on-table result. In this patient, we did not need to perform any inferior skin resection or deepithelialization. However, in patients with vertical skin excess inferior to the nipple-arilar complex, a conservative horizontal full thickness wedge excision can't be performed or the skin deepithelialized to function as an autoderm sling, both resulting in an inverted T scar. We tend to use the Pravena Bellaform wound vac system to promote incisional healing and bolster and stabilize the reconstruction.

mastopexy

nipple-sparing mastectomy

implant reconstruction

pre-pectoral reconstruction

fat grafting