PRS Journal Club: Evolving Trends in Breast Reconstruction

Robot-assisted techniques have revolutionized several surgical specialties, yet their implementation in plastic surgery has been limited, likely given the relatively easier access to the surgical anatomy of interest. Nipple-sparing mastectomies have started to see robotic approaches, which have compelled plastic surgeons to consider alternatives in corresponding free flap procedures that can accommodate these technique modifications. On the other hand, given the cost and learning curve of implementing robotic techniques, some plastic surgeons are attempting to tailor the concepts of robotically pioneered procedures by readapting them to be performed with conventional instruments to promote wider access to different patient populations. Despite these sophisticated approaches to breast reconstruction by plastic surgeons, recent data have shown that general surgeons have eclipsed plastic surgeons in the number of breast reconstruction procedures performed, calling further attention to limitations in patient access to adequate reconstructive surgical care. Traditionally, mastectomies have been performed as open procedures, with subsequent reconstruction performed through the same incision. Three recent clinical trials studied mastectomies performed robotically through minimally invasive incisions. In patients preferring autologous reconstruction, deep inferior epigastric perforator flaps have been difficult to fit into the breast pocket through the small robotic trochar incisions. The profunda artery perforator (PAP) flap offers an excellent option for breast reconstruction when the abdomen is not available, given its long pedicle, hidden scar, and ability to cone the tissue.1 The PAP flap provides adequate volume for breast reconstruction in appropriately selected patients, and its complication profile is similar to those of other free tissue breast reconstruction options.2 Stacking the PAP flap is also an option to provide additional volume.3 In the first Journal Club article, "Robotic Nipple-Sparing Mastectomy and Breast Reconstruction with Profunda Artery Perforator Flaps," Haddock et al.4 investigated the PAP flap as an alternative autologous option to be used in robotic cases. They demonstrated that the PAP flap can be harvested as a long ellipse that can be placed via these smaller robotic incisions and subsequently coned into shape. While the PAP flap was initially performed in an immediate delayed fashion, with increased experience, the authors were able to harvest the PAP flap simultaneously with the robotic mastectomy. Interestingly, harvesting the autologous donor flaps turned out to be easier from an ergonomic standpoint, given the limited space occupied by the robot compared with an additional surgical team. Nipple-sparing mastectomy is gaining popularity in oncologically appropriate candidates because of its aesthetic and psychological benefits.5 Robotically assisted techniques have introduced laterothoracic incisions for mastectomies, which offer improved flexibility and the ability to conceal scars. However, robot-assisted procedures have substantial costs and learning curves. Inframammary fold incisions have historically been popular given their lower nipple necrosis rates compared with periareolar incisions.6 Nevertheless, alternative options for incisions are available. In the second Journal Club article, "Technical Refinements of the Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: The Laterothoracic Approach without Robotic Assistance," Pozzo et al.7 introduced a laterothoracic upper lateral mammary fold incision without the need for robotic assistance, effectively achieving similar aesthetic goals by concealing scars while ensuring oncologic safety. This technique can be used with implant-based methods or free flap techniques, allowing anastomosis to the nearby circumflex scapular vessels.8 While high-level advances are made across plastic surgery for breast reconstruction after mastectomy, there has been speculation that nonplastic surgeons have begun to perform these procedures, which may be influenced by several factors. Geographic limitation has been an established barrier to patients seeking breast reconstruction after mastectomy.9,10 Other studies have found that fewer plastic surgeons are performing these procedures due to perceived poor reimbursement by third-party payers.11 In addition, trends have indicated that implant-based reconstruction has increased significantly over the years.12 In the third Journal Club article, "Assessing the Shift: Increasing Rates of Immediate Breast Reconstruction by Nonplastic Surgeons: Insights from a Nationwide Analysis," Kilmer et al.13 found that general surgeons are increasingly performing oncoplastic and implant-based reconstructions. Surprisingly, they found that these rates have been increasing so rapidly that now general surgeons perform more implant-based breast reconstructions after mastectomy than plastic surgeons. In conclusion, the articles discussed in this month's PRS Journal Club highlight paradigm shifts in breast reconstruction. While some plastic surgeons are pushing the frontiers of robotic approaches, others are innovating alternative incision patterns for nipple-sparing mastectomies performed with conventional instruments. Despite these innovations by plastic surgeons, trends indicate that general surgeons continue to perform a significant percentage of breast reconstructions after mastectomy. Further research will be needed to assess the underlying influences and implications of these trends. DISCLOSURE The authors have no financial or nonfinancial conflicts of interest to disclose.