The feasibility of nipple-sparing mastectomy in combined with abdominal free flap breast reconstruction without skin paddles for flap monitoring: a single-center experience

Background: Nipple-sparing mastectomy in combination with buried abdominal free flap breast reconstruction without leaving any skin paddles for post-operative monitoring might be associated with better cosmetic outcomes. The feasibility of this approach remains unclear while a detailed and validated protocol of post-operative flap monitoring is lacking. Materials and Methods Eligible patients receiving abdominal free-flap breast reconstruction between 2015 and 2020 in our institution were included. Patients were categorized into the buried-flap cohort and the skin-paddle cohort based on whether a skin paddle remained for direct visual monitoring post-operatively. We reported the learning curve of this surgery and the determinants of operative and/or ischemic time. The oncological outcomes and surgical complications rates were also analyzed. Results This study included 147 eligible patients (buried-flap cohort: N = 18; skin-paddle cohort: N = 129). In early-stage patients with immediate breast reconstruction (N = 104), there were no observed relapse events with a median follow-up time of 18 months. The learning curve analysis showed significant reduction of the surgery time and the ischemic time with accumulation of surgical experience after 30 cases. The surgery time and ischemic time were significantly shorter in the buried flap cohort, when compared to that of the skin-paddle cohort. The take-back surgery rates, flap failure rates, and other complication rates were similar between two cohorts under the intra- and post-operative monitoring protocol. Conclusion This study supported the feasibility of autologous abdominal free-flap breast reconstruction using the buried flap approach, and we validated our intra- and post-operative monitoring protocol. A multicenter and prospective study is needed to validate this approach. Trial registration： NCT05560633