title: Skin Flap Necrosis After Mastectomy With Reconstruction: A Prospective Study.
abstract: BACKGROUND
  Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can have an impact on cosmetic outcomes and patient satisfaction, and in worst cases can potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors.
  
  
  METHODS
  A prospective study was designed to capture the rate of skin flap necrosis as well as pre-, intra-, and postoperative variables, with follow-up assessment to 8 weeks postoperatively. Uni- and multivariate analyses were performed for factors associated with skin flap necrosis.
  
  
  RESULTS
  Of 606 consecutive procedures, 85 (14 %) had some level of skin flap necrosis: 46 mild (8 %), 6 moderate (1 %), 31 severe (5 %), and 2 uncategorized (0.3 %). Univariate analysis for any necrosis showed smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal to be significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. Univariate analysis of only moderate or severe necrosis showed body mass index, diabetes, nipple-sparing mastectomy, specimen size, and expander size to be significant. Multivariate analysis showed nipple-sparing mastectomy and specimen size to be significant. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity.
  
  
  CONCLUSIONS
  Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited the impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.
authors.affiliation: Breast Care Team, Department of Surgery, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA. cindy.matsen@hsc.utah.edu.
authors.forename: Cindy B
authors.initials: CB
authors.lastname: Matsen
authors.affiliation: Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Babak
authors.initials: B
authors.lastname: Mehrara
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Anne
authors.initials: A
authors.lastname: Eaton
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Capko
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Anastasia
authors.initials: A
authors.lastname: Berg
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Stempel
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Kimberly J
authors.initials: KJ
authors.lastname: Van Zee
authors.affiliation: Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Pusic
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. wus@mskcc.org.
authors.forename: Tari A
authors.initials: TA
authors.lastname: King
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Hiram S
authors.initials: HS
authors.lastname: Cody
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Pilewskie
authors.affiliation: Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Cordeiro
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Lisa
authors.initials: L
authors.lastname: Sclafani
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: George
authors.initials: G
authors.lastname: Plitas
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Mary L
authors.initials: ML
authors.lastname: Gemignani
authors.affiliation: Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Disa
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: El-Tamer
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Monica
authors.initials: M
authors.lastname: Morrow
mesh_terms: D000328:Adult; D000368:Aged; D018427:Breast Implants / Q000009:adverse effects*; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects* / Q000379:methods*; D015412:Mastectomy, Segmental / Q000009:adverse effects*; D008875:Middle Aged; D009336:Necrosis; D009367:Neoplasm Staging; D009558:Nipples; D059351:Organ Sparing Treatments; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D013524:Surgical Flaps / Q000009:adverse effects* / Q000473:pathology*; D055815:Young Adult