Original Study| Volume 23, ISSUE 2, e37-e44, February 2023

Download started.


Improving Decision-making in Prepectoral Direct-to-implant Reconstruction After Nipple Sparing Mastectomy: The Key Role of Flap Thickness Ratio

Published:November 25, 2022DOI:


      We report our experience in direct-to-implant breast reconstruction with prepectoral polyurethane implants, with a focus on intraoperative mastectomy flap thickness compared to preoperative data (flap thickness ratio) as a reliable predictive variable of ischemic complications and reconstructive outcomes (satisfaction with breast).


      The optimization of nipple sparing mastectomy and implant-based reconstruction techniques led to an increase in the popularity of prepectoral reconstruction. The aim of this study is to explore the ratio between the intraoperative and preoperative breast tissue coverage assessment as reliable tool in order to predict the risk of ischemic complications in prepectoral reconstruction.


      We analyzed 124 preoperative digital mammograms of 100 patients who underwent prepectoral implant-based reconstruction. We applied a Rancati modified score for breast tissue coverage classification, adding 4 measurements on the craniocaudal view. The intraoperative mastectomy flap thickness was measured using an intraoperative ultrasound assessment. We investigated the differences between the groups with and without ischemic complications related to the preoperative, intraoperative, and flap thickness ratio data.


      The flap thickness ratio was lower in ischemic complication group compared to no ischemic complication group (0.4 vs. 0.8) with statistically significant differences for all ischemic complication subgroups: major mastectomy flap necrosis (P = .000), minor mastectomy flap necrosis (P = .005), partial nipple areola complex necrosis (P = .007), and implant exposure (P = .001).


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Breast Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Frey JD
        • Salibian AA
        • Karp NS
        • Choi M.
        Implant-based breast reconstruction: hot topics, controversies, and new directions.
        Plast Reconstr Surg. 2019; 143: 404e-416e
        • Snyderman RK
        • Guthrie RH.
        Reconstruction of the female breast following radical mastectomy.
        Plast Reconstr Surg. 1971; 47: 565-567
        • Rebowe RE
        • Allred LJ
        • Nahabedian MY.
        The evolution from subcutaneous to prepectoral prosthetic breast reconstruction.
        Plast Reconstr Surg Glob Open. 2018; 6: e1797
        • Rancati AO
        • Angrigiani CH
        • Hammond DC
        • et al.
        Direct to implant reconstruction in nipple sparing mastectomy: patient selection by preoperative digital mammogram.
        Plast Reconstr Surg Glob Open. 2017; 5 (PMID:28740781; PMCID: PMC5505842): e1369
        • Rancati A
        • Angrigiani C
        • Hammond D
        • et al.
        Preoperative digital mammography imaging in conservative mastectomy and immediate reconstruction.
        Gland Surg. 2016; 5 (PMID:26855903; PMCID: PMC4716857): 9-14
        • Phillips BT
        • Lanier ST
        • Conkling N
        • et al.
        Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.
        Plast Reconstr Surg. 2012; 129: 778e-788e
        • Salgarello M
        • Pagliara D
        • Barone Adesi L
        • Visconti G
        • Wild JB
        • Matey P.
        Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction.
        Clin Breast Cancer. 2021; 21: e454-e461
        • Salgarello M
        • Adesi LB
        • Visconti G
        • Pagliara DM
        • Mangialardi ML.
        Considerations for performing immediate breast reconstruction during the COVID-19 pandemic.
        Breast J. 2020; 26: 1485-1487
        • Pagliara D
        • Maxia S
        • Faenza M
        • Dessena L
        • Campus G
        • Rubino C.
        Low versus high vacuum suction drainage of the submuscular pocket in primary breast reconstruction: a retrospective study.
        Ann Plast Surg. 2018; 80: 339-343
        • Pagliara D
        • Vitagliano S
        • Mangialardi ML
        • et al.
        The role of fat grafting on contracted breast implant capsules: A retrospective comparative histological and immunohistochemical study.
        J Plast Reconstr Aesthet Surg. 2022; 75: 1083-1093
        • Pusic AL
        • Klassen AF
        • Scott AM
        • Klok JA
        • Cordeiro PG
        • Cano SJ
        Developmentof a new patient-reported outcome measure for breast surgery: the BREAST-Q.
        Plast Reconstr Surg. 2009; 124: 345-353
        • Pusic AL
        • Lemaine V
        • Klassen AF
        • Scott AM
        • Cano SJ.
        Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine.
        Plast Reconstr Surg. 2011; 127: 1361-1367
        • Sbitany H.
        Important considerations for performing prepectoral breast reconstruction.
        Plast Reconstr Surg. 2017; 140: 7S-13S
        • Vidya R
        • Masià J
        • Cawthorn S
        • et al.
        Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases.
        Breast J. 2017; 23: 670-676
        • Larson DL
        • Basir Z
        • Bruce T.
        Is oncologic safety compatible with a predictably viable mastectomy skin flap?.
        Plast Reconstr Surg. 2011; 127: 27-33
        • Robertson SA
        • Rusby JE
        • Cutress RI.
        Determinants of optimal mastectomy skin flap thickness.
        Br J Surg. 2014; 101: 899-911
        • Frey JD
        • Salibian AA
        • Choi M
        • Karp NS.
        Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging.
        Plast Reconstr Surg Glob Open. 2017; 5: e1439
        • Hamdi M.
        Association between breast implant- associated anaplastic large celllymphoma (BIA-ALCL) risk and polyurethane breast implants: clinical evidenceand European PERSPECTIVE.
        Aesthet Surg J. 2019; 39: S49-S54
        • Sigalove S
        • Maxwell GP
        • Sigalove N
        • et al.
        Prepectoral implant-based breastreconstruction and postmastectomy radiotherapy: short-term outcomes.
        PRSGO. 2017; 5: e1631
        • Castel N
        • Soon-Sutton T
        • Deptula P
        • et al.
        Polyurethane-coated breast implantsrevisited: a 30-year follow-up.
        Arch Plast Surg. 2015; 42: 186-193
        • Jones P
        • Mempin M
        • Hu H
        • et al.
        The functional influence of breast implantouter shell morphology on bacterial attachmentand growth.
        Plast Reconstr Surg. 2018; 142: 837-849