Modified Bidirectional Adipodermal Mastopexy, Nipple-sparing Mastectomy, and Direct-to-implant Reconstruction in Patients with Significant Ptosis

Background: Nipple-sparing mastectomy (NSM) and direct-to-implant reconstruction (DTIR) allow patients to complete their surgical care in one surgery. However, for women with significant ptosis, NSM is frequently not offered or requires multiple procedures. Methods: We performed a retrospective review of a single-surgeon practice from 2016 to 2021 of a single-stage, modified, bidirectional adipodermal mastopexy to facilitate NSM and DTIR in patients with breast cancer and grades 2-3 ptosis. Demographics, intraoperative details, and postoperative outcomes were recorded. We also conducted a literature review and compared our technique to previously published approaches. Results: Sixty breast cancer patients (105 breasts) with grades 2-3 ptosis underwent NSM and prepectoral DTIR using this technique. The average nipple-areola complex (NAC) lift was 9cm (range, 4 -15cm), and the average preoperative nipple to inframammary fold distance was 12cm (range, 8 -17cm). Overall complications included seroma [n = 8 (8%)], T-junction dehiscence [n = 6 (6%)], mastectomy flap necrosis [n = 6 (6%)], and superficial/partial NAC necrosis [n = 2 (2%)] with no incidence of complete NAC necrosis. Comprehensive literature review confirmed that the modified, bidirectional adipodermal mastopexy has a favorable complication profile when compared with other previously described approaches despite its application to more challenging patient populations undergoing DTIR. Conclusions: The modified bidirectional adipodermal mastopexy safely facilitates NSM and DTIR in breast cancer patients with ptosis without requiring multiple procedures or leaving behind breast tissue and, in our hands, is the preferred approach in this difficult patient population.