Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction

by Turin, Sergey Y.; Li, Daniel D.; Vaca, Elbert E.; Fine, Neil  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 264e–270e

Background: Mastectomy flap necrosis remains a challenging complication in immediate tissue expander breast reconstruction. Nitroglycerin ointment has been shown to reduce the incidence of mastectomy flap necrosis in a randomized controlled study, using 45 g per breast and treating one side only in bilateral cases. This study was conducted to determine the efficacy of 15 g of nitroglycerin ointment per breast, therefore permitting application to both breasts in cases of bilateral mastectomy. Methods: A retrospective cohort study of patients undergoing immediate tissue expander breast reconstruction performed by a single reconstructive surgeon was conducted. The intervention cohort consisted of all patients between June 10, 2015, and June 9, 2016 (94 patients, 158 breasts), where 15 g of nitroglycerin ointment was routinely applied per breast. The control cohort consisted of all patients from June 10, 2014, to June 9, 2015 (107 patients, 170 breasts), where nitroglycerin was not applied. All complications were tracked, including minor wound healing problems. Results: There was an overall 22 percent decreased incidence of mastectomy flap necrosis in the nitroglycerin ointment cohort (47.5 percent versus 60.6 percent; p = 0.002), with a 44 percent reduction in full-thickness mastectomy flap necrosis that trended toward statistical significance (9.5 percent versus 16.5 percent; p = 0.06). On multivariate analysis, nitroglycerin application was independently associated with a decrease in mastectomy flap necrosis or need for mastectomy flap débridement. There was no significant difference in the incidence of postoperative hypotension (3.8 percent versus 2.9 percent) or headache among cohorts. Conclusion: Topical nitroglycerin ointment application to mastectomy skin flaps at 15 g per breast is a cost-effective means of decreasing the incidence of mastectomy flap necrosis in unilateral and bilateral immediate tissue expander breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

Plastic & Reconstructive Surgery:
September 2016 - Volume 138 - Issue 3 - p 558–566

Kim, DY et al

Background: Mastectomy flap necrosis is one of the most common and significant complications in immediate expander-based breast reconstruction. Negative-pressure wound therapy is widely used for open wounds but is not commonly used for closed incisional wounds. However, the postoperative use of incisional negative-pressure wound therapy is demonstrated to reduce complication rates. The authors evaluate the incidence of mastectomy flap necrosis in patients with incisional negative-pressure wound therapy after immediate expander-based breast reconstruction compared with the incidence in patients with conventional dressing. Methods: A retrospective review was conducted to identify patients who underwent immediate expander-based breast reconstruction between January of 2010 and February of 2015 at a single institution. Patients were divided into a conventional dressing group and an incisional negative-pressure wound therapy group. Patient demographics, intraoperative findings, and complications were compared between the two groups. Results: A total of 228 breasts (206 patients) were included in this study. Of these, the incisional negative-pressure wound therapy group included 45 breasts (44 patients) and the conventional dressing group included 183 breasts (162 patients). The incisional negative-pressure wound therapy group had a lower overall complication rate (11.1 percent versus 27.9 percent; p = 0.019), overall mastectomy flap necrosis rate (8.9 percent versus 23.5 percent; p = 0.030), and major mastectomy flap necrosis rate (2.2 percent versus 13.7 percent; p = 0.031) compared with the conventional dressing group. Conclusions: Incisional negative-pressure wound therapy reduced the incidence of mastectomy flap necrosis. This simple and reliable dressing technique can be effective in preventing mastectomy flap necrosis in immediate expander-based breast reconstruction.