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Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 1303e1308
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants G. Querci della Rovere a,*, M. Nava b, R. Bonomi a, G. Catanuto b, J.R. Benson c a
Department of Surgery, The Royal Marsden Hospital, Down’s Road, Sutton, Surrey SM2 5PT, UK Instituto Nazionale Tumori, Milan, Italy c Cambridge Breast Unit, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK b
Received 8 August 2006; accepted 22 June 2007
KEYWORDS Breast cancer; Breast reconstruction; Prophylactic mastectomy
Summary One of the difficulties of an immediate breast reconstruction with a sub-pectoral tissue expander is fashioning the lower, medial end of the pouch because of the insertion of the fibres of the pectoral muscle into the ribs. This often requires delayed corrections to provide a good cosmetic result with fullness of the lower medial quadrant of the reconstructed breast. Skin-reducing mastectomy (SRM) is a technique that potentially resolves this cosmetic problem by creating a dermomuscular pouch with adequate volume in the lower-medial quadrant and, at the same time, provides satisfactory coverage of the silicone implant. Much of the surgical scarring lies in relatively concealed areas of the breast. The risk of complications is reduced by use of permanent expanders and achieving compatibility between the length of the skin flaps and that of the dermomuscular pouch. The indications for this technique are the same as those of a skin-sparing mastectomy. The procedure is particularly useful for women with large breasts and in cases of bilateral prophylactic mastectomy for women at increased risk of breast cancer We report our experience with 18 skin-reducing mastectomies carried out in 10 women. One had a complication (5%) (haematoma and infection) and one had poor long-term cosmetic result (5%) (fibrosis of the lower pole of the reconstructed breast). SRM is, from an oncological perspective, a skin-sparing mastectomy (type IV) that provides a good cosmetic result by creating a dermomuscular pouch. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (G. Querci della Rovere).
One of the difficulties of an immediate breast reconstruction with a sub-pectoral tissue expander is the lack of space at the lower, medial end of the pouch because of the insertion of the fibres of the pectoral major muscle into the ribs. This often requires either the detachment of the
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.032
1304 muscular insertions into the ribs, leaving the silicone implant in the subcutaneous space or delayed corrections to provide a good cosmetic result with fullness of the lower medial quadrant of the reconstructed breast. This problem can be overcome in women with large, ptotic breasts requiring significant reduction of the ipsilateral skin envelope at the time of mastectomy. Redundant skin can be removed, either as a conventional ellipse around the nipple-areola complex or, preferably, as part of a Wise pattern inverted ‘T’ incision, which is typically used for reduction mammoplasty. In 1990, Bostwick1 first described the technique we report in this paper that could be defined as a variant form of type IV skin-sparing mastectomy (SSM) with a dermomuscular pouch. The technique combines a skin-sparing mastectomy with simultaneous reduction of the breast skin envelope; it accords with the oncological principles of a skin-sparing mastectomy and also incorporates a lower dermal flap, which is used to create a dermo-muscular pouch to reinforce coverage of the implant. When implant-only reconstruction is undertaken, breast volume can be restored using either a permanent tissue expander or a fixed volume silicone implant.2 The use of skin-sparing techniques3e9 have reduced the need for skin expansion, but placement of an implant in the subpectoral location can still present technical challenges when dissecting the pouch and attempting to obtain satisfactory coverage of the implant. Lack of complete muscle coverage of the implant can increase the risk of implant exposure, particularly in the vicinity of the inframammary fold where the implant may lie directly beneath the skin wound. Furthermore, a fixed volume implant may also be associated with some tension on the relatively long skin flaps when an inverted T procedure has been used to reduce the skin envelope. This can lead to problems with wound healing and even skin necrosis at the junction of the ‘T’. The technique that we describe allows complete release of the pectoralis muscle inferiorly, yet provides total implant coverage with a dermo-muscular layer. By augmenting the pouch and providing an additional tissue layer at the lower pole of the breast, this technique may reduce the risk of complications and improve the cosmetic result. The Bostwick technique, not widely known and practised, was revived by two of the authors (MN, GQDR), and renamed ‘Skin-reducing mastectomy (SRM).10 The experience of the Istituto Nazionale Tumori, Milan, Italy, using a fixed volume implant, has been reported elsewhere.2 In this paper, we report the experience at the Royal Marsden Hospital using the skin-reducing technique in conjunction with a tissue expander.
G. Querci della Rovere et al. invasive breast cancer underwent modified radical mastectomy (SRM) and contralateral prophylactic SRM (four procedures); (2) two patients with widespread ductal carcinoma in situ (DCIS) who underwent simple mastectomy (SRM) and contralateral superior pedicle breast reduction (two procedures); (3) five patients underwent bilateral prophylactic SRM for high personal risk assessment (family history breast cancer, pre-malignant lesions) (10 procedures); and (4) one patient who had previously been treated with breast-conservation surgery for a nodepositive, invasive ductal carcinoma developed widespread DCIS and underwent bilateral simple mastectomy with an SRM technique (two procedures). Permanent non-biodimensional tissue expanders (Becker 25 or 50) were used in all cases, except one in which a temporary expander was chosen.
Technique The surgical technique combines the conventional incision for breast reduction (Wise pattern) with preservation of an inferior dermal flap. The latter is used to reinforce and enlarge the subpectoral pouch, which will receive the implant. Preoperative markings The future position of the new nipple is marked along the mid-clavicular line, about 19e23 cm from the sternal notch (depending on the level of the inframammary fold) (Figure 1). A slightly modified Wise pattern incision is used for SRM; from this point, marking the position of the new nipple, two oblique lines 7 cm long are drawn, forming an angle
Patients and methods A total of 18 skin-reducing mastectomies were carried out among 10 women between August 2002 and June 2005. The median age of the women was 49 years (range 32e59 years). Selective criteria for this procedure were either women with large ptotic breasts eligible for a skin-sparing mastectomy for breast cancer or for prophylaxis. The distribution of cases was as follows: (1) two women with unilateral
Figure 1 Preoperative markings: the dashed area indicates the de-epitheliasation of the dermal flap. A, hypothetical new nipple position; B,C, medial and lateral vertical lines (7 cm long). The wider the angle at point A the greater the amount of skin reduction; D, triangle of epidermis preserved at the mid-clavicular point to reduce tension during closure of the skin.
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants
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of 30e90 . The ends of the two oblique lines are then extended laterally and medially at an angle of 90 to join the inframammary line. The mid-clavicular point is also marked below the inframammary fold. The precise dimensions of these markings depends on the proposed extent of skin reduction. Surgical procedure A horizontal full-thickness skin incision is made along the two oblique lines and then continued along their corresponding medial and lateral extensions. The incision along the inframammary line is made only through the epidermis and must not be deepened into the dermal plane. A small triangle of epidermis can be preserved at the mid-clavicular point of the inframammary incision to reduce the tension at the inverted ‘T’ junction during skin closure. A dermal flap is then created within the area between the inframammary line and the medial and lateral incisions of the reduction pattern (Figure 2). A formal mastectomy is then carried out with dissection along the subcutaneous planes, such that all breast tissue is removed and the subdermal vasculature is protected. This will preserve the subdermal vasculature and viability of both the skin and dermal flaps, while ensuring excision of all breast parenchymal tissue (Figure 3). When axillary surgery is indicated, this can usually be carried out through the mastectomy wound, but sometimes an additional incision in the axilla is required. Once the mastectomy has been completed, breast reconstruction commences with an incision along the lateral border of the pectoralis major muscle, and a submuscular pocket is created deep to both the pectoral and serratus muscles. The lowermost insertions of pectoralis major, lying inferiorly and inferomedially, are divided and the muscle sutured to the upper border of the dermal flap (Figure 4). An appropriate size and type of permanent tissue expander is placed in the resultant submuscular, dermal pouch, and a suction drain placed at this level. When a port is present, this is positioned on the anterior chest wall infero-laterally below the inframammary fold. Once the implant is in place, the size of the pouch can be
Figure 2 Skin incisions and dermal flap de-epithelialised. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
Figure 3 Dermal flap dissected from the lower part of the breast. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
adjusted with further dissection so that the implant is optimally positioned within the pouch. Closure of the pouch starts medially with approximation of the pectoralis major and the dermal flap, and proceeds laterally. Before this is completed, two new sutures are inserted at the proximal end between the lateral border of pectoralis and the serratus muscles and at the distal end between the lateral border of the dermal flap and the serratus anterior muscle. As closure of the pouch proceeds, these three sutures will be joined together (Figure 5), achieving total coverage of the tissue expander. An important principle of this technique is that the length of the skin flaps match the combined length of the pectoral muscle and dermal flap. In particular, the volume of the pouch should not be disproportionate to the skin envelope in order to avoid excessive tension on the skin. It
Figure 4 The inferior margin of the pectoralis major and the dermal flap are partially sutured, and a tissue expander is positioned under the dermo-pectoral pouch. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
1306
G. Querci della Rovere et al. in all cases, which was of the permanent type (25% or 50%). In three patients managed with bilateral skin-reducing mastectomies, the tissue expander was subsequently exchanged for a fixed-volume silicone contoured implant. There was one complication among these 18 procedures; in one case, the patient developed a postoperative haematoma, which was managed conservatively. This subsequently become infected, necessitating removal of the implant. One woman who had undergone SRM and a contralateral reduction also had a poor cosmetic result at 24 months after surgery. This was due to scarring and fibrosis at the lower pole of the reconstructed breast, leading to marked asymmetry with the reduced contralateral breast, which was also relatively ptotic. This was managed by excision of the scarred tissue and importation of fresh skin from a latissimus dorsi myocutaneous flap. A contralateral mastopexy was carried out to achieve symmetry. At a median follow-up of 27 months (range 61e6 months), there have been no local recurrences (although few patients had cancer).
Discussion
Figure 5 The achievement of complete closure of the pouch by convergence of the three sutures: between the pectoral major and serratus anterior, pectoral major and dermal flap and dermal flap (lateral aspect) and serratus anterior.
has been reported that there should be a minimum distance of 8 cm from nipple to inframammary fold10; however, in our opinion, this restriction can be overcome by taking the upper limit of the dermal flap above the level of the nipple and, if necessary, excising the nipple with the breast tissue using a vertical elliptical incision. The resultant vertical split on the dermal flap can be repaired with absorbable material at the time of closure of the dermomuscular pouch. Closure of the skin wound is accomplished by approximating the lower ends of the two oblique lines at the midclavicular point of the inframammary fold. Either one or two suction drains can be used. Nipple reconstruction (local anaesthetic) is best undertaken as a second-stage procedure when the reconstructed breast is fully healed and ‘settled’. Prosthetic, adhesive nipples are an alternative option, and can be fashioned from a mould of the original (ipsilateral) or contralateral nipple. When oncological mandates permit, the native nipple can be preserved and shifted upwards to a new position using a Wise pattern incision and a superior dermal pedicle. A free nipple graft can be considered in some circumstances as a method of nipple reconstruction. All patients undergoing nipple preservation must be warned of the risk of nipple necrosis.
Results A total of 18 SRM procedures were undertaken among 10 patients. A Becker round tissue expander was used initially
For some women with moderate to larger sized breasts, optimum cosmetic results from immediate reconstruction are achieved by combining a conventional skin-sparing mastectomy with a degree of skin-envelope reduction in conjunction with a contralateral reduction mammoplasty or mastopexy. When large amounts of skin are preserved, the flaps are necessarily longer and are at higher risk of skin necrosis. Moreover, when there is a marked disparity between the volume of the skin envelope relative to the pouch, any redundant skin will tend to wrinkle and detract from the final cosmetic result. Sometimes, this can be compensated for by subsequent expansion of the submuscular pouch, but usually it is preferable to have an appropriate amount of skin at the time of the primary surgical procedure. The late John Bostwick III described a modified form of skin-sparing mastectomy in 1990, whereby the breast parenchyma was removed via a Wise pattern inverted ‘T’ type skin incision. A musculo-dermal pouch was created for a definitive permanent silicone prosthesis. The procedure was done primarily for prophylactic parenchymal resections.1 This technique provided more space within the lower quadrants, additional protection for the implant, and also helped establish ptosis in the lower pole of the reconstructed breast.10 Hammond et al.11 applied Bostwick’s technique to breast reconstruction after therapeutic resections for cancer. A particular feature of their adaptation was the initial insertion of a temporary tissue expander in most patients, and its subsequent replacement with a permanent implant as a delayed procedure. By contrast, in Milan, Nava et al.2 used this technique to undertake immediate breast reconstruction as a single step operation in which a definitive anatomical prosthesis was positioned within a relatively large dermo-muscular pouch. Thus, the shape and volume of the reconstructed breast was determined at the time of primary surgery. Careful preservation of the inframammary fold encouraged immediate natural ptosis, together with the greater capacity of the lower portion of the pouch.12 Furthermore, this technique (in the Milan
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants
Figure 6 Early postoperative appearance after right skinreducing mastectomy with immediate reconstruction (500 cc Expander) and simultaneous left breast reduction.
series) allowed the use of larger breast prostheses (medium volume 432 ml), which would otherwise be difficult to accommodate within a conventional subpectoral pocket. At our own institution, the decision was taken to use permanent round Becker expanders (25% or 50%). These offered the potential advantages of (1) allowing a degree of flexibility in selecting the final volume of the reconstructed breast (taking account of the patient’s wishes); and (2) reducing the initial tension on the skin flaps and minimising the chance of flap necrosis without compromising the final volume attained. In a series of inverted ‘T’ mastectomies, relatively high rates of complications (up to 27%), most commonly involving problems of skin viability at the inverted ‘T’ junction were reported.9,13 Among the 10 women (18 procedures) reported here, only one woman (10% of all patients and 5.5% of all procedures) required removal of the expander owing to complications of haematoma and infection. Nava et al., in Milan,2 found that one-fifth (20%) of patients suffered severe complications, with an implant failure rate of 13%. These problems were significantly more frequent in heavy smokers for whom the sustained
1307
Figure 8 Postoperative view after change of expanders with silicone implants.
viability of thinner and longer flaps is less certain. Of note, three-quarters of cases requiring implant removal occurred in women smoking more than 20 cigarettes per day. The higher incidence of implant failure in the Milan series may be attributable to the use of fixed volume implants rather than tissue expanders, which allow gradual expansion according to the condition of the skin flaps. There tends to be excess pouch volume relative to skin envelope, the latter has been reduced whereas the former enhanced in size. The skin flaps need time to adjust and recover without undue tension caused by an underlying implant. An expander allows for this phased increase in skin tension, and is less likely to be associated with skin necrosis. Figures 6e8 show the favourable cosmetic results achievable with this technique of skin-reducing mastectomy. Levels of satisfaction were high among both clinicians and patients, particularly with the contour of the breast and degree of ptosis. It is unknown whether this form of reconstruction is compatible with postoperative chest wall irradiation. However, as the implant is well covered, this should help reduce the main sequelae of radiotherapy, such as capsular contracture. One of the women had received prior breast irradiation after initial breastconservation surgery for invasive malignancy, with no adverse effect on the cosmetic result to date. In conclusion, SRM is a good technique for implant-only breast reconstruction in women with large breasts who do not require postoperative radiotherapy. We would recommend the use of permanent tissue expanders in preference to fixed volume silicone implants as this, in our experience, has a low incidence of complications and provides good subjective cosmetic results.
References
Figure 7 Postoperative view after therapeutic left mastectomy and contra-lateral prophylactic mastectomy.
1. Bostwick J, editor. Total mastectomy with breast skin and volume reduction using an inverted ‘T’ incision. Plastic and reconstructive breast surgery. St Louis: Quality Medical Publisher Inc; 1990. p. 1048e54. 2. Nava M, Cortinovis U, Ottolenghi J, et al. Skin reducing mastectomy. Plast Reconstr Surg 2006;118:603e10. 3. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg 1991;87:1048e53.
1308 4. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg 1998;102:49e62. 5. Rivadeneira DE, Simmons RM, Fish SK, et al. Skinsparing mastectomy with immediate breast reconstruction: a critical analysis of local recurrence. Cancer J 2000;6: 331e5. 6. Kroll SS, Khoo A, Singletary SE. Local recurrence risk after skinsparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg 1999;104:421e5. 7. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 1999; 6:676e81. 8. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and
G. Querci della Rovere et al.
9.
10.
11.
12.
13.
immediate breast reconstruction for invasive breast cancer. Ann Surg 2002;235:814e9. Carlson GW, Bostwick 3rd J, Styblo TM, et al. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 1997;225:570e5. Querci della Rovere G, Benson JR, Breach N, Nava M, editors. Oncoplastic and reconstructive surgery of the breast. London: Taylor and Francis Group; 2004. p. 21e31. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skin-sparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002;110:206e11. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 1998;102:1034e45. Hudson DA, Skoll PJ. Single Stage autologus breast restoration. Plast Reconstr Surg 2001;108:1163e71.
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants G. Querci della Rovere a,*, M. Nava b, R. Bonomi a, G. Catanuto b, J.R. Benson c a
Department of Surgery, The Royal Marsden Hospital, Down’s Road, Sutton, Surrey SM2 5PT, UK Instituto Nazionale Tumori, Milan, Italy c Cambridge Breast Unit, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UK b
Received 8 August 2006; accepted 22 June 2007
KEYWORDS Breast cancer; Breast reconstruction; Prophylactic mastectomy
Summary One of the difficulties of an immediate breast reconstruction with a sub-pectoral tissue expander is fashioning the lower, medial end of the pouch because of the insertion of the fibres of the pectoral muscle into the ribs. This often requires delayed corrections to provide a good cosmetic result with fullness of the lower medial quadrant of the reconstructed breast. Skin-reducing mastectomy (SRM) is a technique that potentially resolves this cosmetic problem by creating a dermomuscular pouch with adequate volume in the lower-medial quadrant and, at the same time, provides satisfactory coverage of the silicone implant. Much of the surgical scarring lies in relatively concealed areas of the breast. The risk of complications is reduced by use of permanent expanders and achieving compatibility between the length of the skin flaps and that of the dermomuscular pouch. The indications for this technique are the same as those of a skin-sparing mastectomy. The procedure is particularly useful for women with large breasts and in cases of bilateral prophylactic mastectomy for women at increased risk of breast cancer We report our experience with 18 skin-reducing mastectomies carried out in 10 women. One had a complication (5%) (haematoma and infection) and one had poor long-term cosmetic result (5%) (fibrosis of the lower pole of the reconstructed breast). SRM is, from an oncological perspective, a skin-sparing mastectomy (type IV) that provides a good cosmetic result by creating a dermomuscular pouch. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (G. Querci della Rovere).
One of the difficulties of an immediate breast reconstruction with a sub-pectoral tissue expander is the lack of space at the lower, medial end of the pouch because of the insertion of the fibres of the pectoral major muscle into the ribs. This often requires either the detachment of the
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.032
1304 muscular insertions into the ribs, leaving the silicone implant in the subcutaneous space or delayed corrections to provide a good cosmetic result with fullness of the lower medial quadrant of the reconstructed breast. This problem can be overcome in women with large, ptotic breasts requiring significant reduction of the ipsilateral skin envelope at the time of mastectomy. Redundant skin can be removed, either as a conventional ellipse around the nipple-areola complex or, preferably, as part of a Wise pattern inverted ‘T’ incision, which is typically used for reduction mammoplasty. In 1990, Bostwick1 first described the technique we report in this paper that could be defined as a variant form of type IV skin-sparing mastectomy (SSM) with a dermomuscular pouch. The technique combines a skin-sparing mastectomy with simultaneous reduction of the breast skin envelope; it accords with the oncological principles of a skin-sparing mastectomy and also incorporates a lower dermal flap, which is used to create a dermo-muscular pouch to reinforce coverage of the implant. When implant-only reconstruction is undertaken, breast volume can be restored using either a permanent tissue expander or a fixed volume silicone implant.2 The use of skin-sparing techniques3e9 have reduced the need for skin expansion, but placement of an implant in the subpectoral location can still present technical challenges when dissecting the pouch and attempting to obtain satisfactory coverage of the implant. Lack of complete muscle coverage of the implant can increase the risk of implant exposure, particularly in the vicinity of the inframammary fold where the implant may lie directly beneath the skin wound. Furthermore, a fixed volume implant may also be associated with some tension on the relatively long skin flaps when an inverted T procedure has been used to reduce the skin envelope. This can lead to problems with wound healing and even skin necrosis at the junction of the ‘T’. The technique that we describe allows complete release of the pectoralis muscle inferiorly, yet provides total implant coverage with a dermo-muscular layer. By augmenting the pouch and providing an additional tissue layer at the lower pole of the breast, this technique may reduce the risk of complications and improve the cosmetic result. The Bostwick technique, not widely known and practised, was revived by two of the authors (MN, GQDR), and renamed ‘Skin-reducing mastectomy (SRM).10 The experience of the Istituto Nazionale Tumori, Milan, Italy, using a fixed volume implant, has been reported elsewhere.2 In this paper, we report the experience at the Royal Marsden Hospital using the skin-reducing technique in conjunction with a tissue expander.
G. Querci della Rovere et al. invasive breast cancer underwent modified radical mastectomy (SRM) and contralateral prophylactic SRM (four procedures); (2) two patients with widespread ductal carcinoma in situ (DCIS) who underwent simple mastectomy (SRM) and contralateral superior pedicle breast reduction (two procedures); (3) five patients underwent bilateral prophylactic SRM for high personal risk assessment (family history breast cancer, pre-malignant lesions) (10 procedures); and (4) one patient who had previously been treated with breast-conservation surgery for a nodepositive, invasive ductal carcinoma developed widespread DCIS and underwent bilateral simple mastectomy with an SRM technique (two procedures). Permanent non-biodimensional tissue expanders (Becker 25 or 50) were used in all cases, except one in which a temporary expander was chosen.
Technique The surgical technique combines the conventional incision for breast reduction (Wise pattern) with preservation of an inferior dermal flap. The latter is used to reinforce and enlarge the subpectoral pouch, which will receive the implant. Preoperative markings The future position of the new nipple is marked along the mid-clavicular line, about 19e23 cm from the sternal notch (depending on the level of the inframammary fold) (Figure 1). A slightly modified Wise pattern incision is used for SRM; from this point, marking the position of the new nipple, two oblique lines 7 cm long are drawn, forming an angle
Patients and methods A total of 18 skin-reducing mastectomies were carried out among 10 women between August 2002 and June 2005. The median age of the women was 49 years (range 32e59 years). Selective criteria for this procedure were either women with large ptotic breasts eligible for a skin-sparing mastectomy for breast cancer or for prophylaxis. The distribution of cases was as follows: (1) two women with unilateral
Figure 1 Preoperative markings: the dashed area indicates the de-epitheliasation of the dermal flap. A, hypothetical new nipple position; B,C, medial and lateral vertical lines (7 cm long). The wider the angle at point A the greater the amount of skin reduction; D, triangle of epidermis preserved at the mid-clavicular point to reduce tension during closure of the skin.
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants
1305
of 30e90 . The ends of the two oblique lines are then extended laterally and medially at an angle of 90 to join the inframammary line. The mid-clavicular point is also marked below the inframammary fold. The precise dimensions of these markings depends on the proposed extent of skin reduction. Surgical procedure A horizontal full-thickness skin incision is made along the two oblique lines and then continued along their corresponding medial and lateral extensions. The incision along the inframammary line is made only through the epidermis and must not be deepened into the dermal plane. A small triangle of epidermis can be preserved at the mid-clavicular point of the inframammary incision to reduce the tension at the inverted ‘T’ junction during skin closure. A dermal flap is then created within the area between the inframammary line and the medial and lateral incisions of the reduction pattern (Figure 2). A formal mastectomy is then carried out with dissection along the subcutaneous planes, such that all breast tissue is removed and the subdermal vasculature is protected. This will preserve the subdermal vasculature and viability of both the skin and dermal flaps, while ensuring excision of all breast parenchymal tissue (Figure 3). When axillary surgery is indicated, this can usually be carried out through the mastectomy wound, but sometimes an additional incision in the axilla is required. Once the mastectomy has been completed, breast reconstruction commences with an incision along the lateral border of the pectoralis major muscle, and a submuscular pocket is created deep to both the pectoral and serratus muscles. The lowermost insertions of pectoralis major, lying inferiorly and inferomedially, are divided and the muscle sutured to the upper border of the dermal flap (Figure 4). An appropriate size and type of permanent tissue expander is placed in the resultant submuscular, dermal pouch, and a suction drain placed at this level. When a port is present, this is positioned on the anterior chest wall infero-laterally below the inframammary fold. Once the implant is in place, the size of the pouch can be
Figure 2 Skin incisions and dermal flap de-epithelialised. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
Figure 3 Dermal flap dissected from the lower part of the breast. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
adjusted with further dissection so that the implant is optimally positioned within the pouch. Closure of the pouch starts medially with approximation of the pectoralis major and the dermal flap, and proceeds laterally. Before this is completed, two new sutures are inserted at the proximal end between the lateral border of pectoralis and the serratus muscles and at the distal end between the lateral border of the dermal flap and the serratus anterior muscle. As closure of the pouch proceeds, these three sutures will be joined together (Figure 5), achieving total coverage of the tissue expander. An important principle of this technique is that the length of the skin flaps match the combined length of the pectoral muscle and dermal flap. In particular, the volume of the pouch should not be disproportionate to the skin envelope in order to avoid excessive tension on the skin. It
Figure 4 The inferior margin of the pectoralis major and the dermal flap are partially sutured, and a tissue expander is positioned under the dermo-pectoral pouch. Reproduced with permission from Taylor and Francis Publishers from: G Querci della Rovere, JR Benson, N Breach, M Nava (eds), Oncoplastic and Reconstructive Surgery of the Breast.
1306
G. Querci della Rovere et al. in all cases, which was of the permanent type (25% or 50%). In three patients managed with bilateral skin-reducing mastectomies, the tissue expander was subsequently exchanged for a fixed-volume silicone contoured implant. There was one complication among these 18 procedures; in one case, the patient developed a postoperative haematoma, which was managed conservatively. This subsequently become infected, necessitating removal of the implant. One woman who had undergone SRM and a contralateral reduction also had a poor cosmetic result at 24 months after surgery. This was due to scarring and fibrosis at the lower pole of the reconstructed breast, leading to marked asymmetry with the reduced contralateral breast, which was also relatively ptotic. This was managed by excision of the scarred tissue and importation of fresh skin from a latissimus dorsi myocutaneous flap. A contralateral mastopexy was carried out to achieve symmetry. At a median follow-up of 27 months (range 61e6 months), there have been no local recurrences (although few patients had cancer).
Discussion
Figure 5 The achievement of complete closure of the pouch by convergence of the three sutures: between the pectoral major and serratus anterior, pectoral major and dermal flap and dermal flap (lateral aspect) and serratus anterior.
has been reported that there should be a minimum distance of 8 cm from nipple to inframammary fold10; however, in our opinion, this restriction can be overcome by taking the upper limit of the dermal flap above the level of the nipple and, if necessary, excising the nipple with the breast tissue using a vertical elliptical incision. The resultant vertical split on the dermal flap can be repaired with absorbable material at the time of closure of the dermomuscular pouch. Closure of the skin wound is accomplished by approximating the lower ends of the two oblique lines at the midclavicular point of the inframammary fold. Either one or two suction drains can be used. Nipple reconstruction (local anaesthetic) is best undertaken as a second-stage procedure when the reconstructed breast is fully healed and ‘settled’. Prosthetic, adhesive nipples are an alternative option, and can be fashioned from a mould of the original (ipsilateral) or contralateral nipple. When oncological mandates permit, the native nipple can be preserved and shifted upwards to a new position using a Wise pattern incision and a superior dermal pedicle. A free nipple graft can be considered in some circumstances as a method of nipple reconstruction. All patients undergoing nipple preservation must be warned of the risk of nipple necrosis.
Results A total of 18 SRM procedures were undertaken among 10 patients. A Becker round tissue expander was used initially
For some women with moderate to larger sized breasts, optimum cosmetic results from immediate reconstruction are achieved by combining a conventional skin-sparing mastectomy with a degree of skin-envelope reduction in conjunction with a contralateral reduction mammoplasty or mastopexy. When large amounts of skin are preserved, the flaps are necessarily longer and are at higher risk of skin necrosis. Moreover, when there is a marked disparity between the volume of the skin envelope relative to the pouch, any redundant skin will tend to wrinkle and detract from the final cosmetic result. Sometimes, this can be compensated for by subsequent expansion of the submuscular pouch, but usually it is preferable to have an appropriate amount of skin at the time of the primary surgical procedure. The late John Bostwick III described a modified form of skin-sparing mastectomy in 1990, whereby the breast parenchyma was removed via a Wise pattern inverted ‘T’ type skin incision. A musculo-dermal pouch was created for a definitive permanent silicone prosthesis. The procedure was done primarily for prophylactic parenchymal resections.1 This technique provided more space within the lower quadrants, additional protection for the implant, and also helped establish ptosis in the lower pole of the reconstructed breast.10 Hammond et al.11 applied Bostwick’s technique to breast reconstruction after therapeutic resections for cancer. A particular feature of their adaptation was the initial insertion of a temporary tissue expander in most patients, and its subsequent replacement with a permanent implant as a delayed procedure. By contrast, in Milan, Nava et al.2 used this technique to undertake immediate breast reconstruction as a single step operation in which a definitive anatomical prosthesis was positioned within a relatively large dermo-muscular pouch. Thus, the shape and volume of the reconstructed breast was determined at the time of primary surgery. Careful preservation of the inframammary fold encouraged immediate natural ptosis, together with the greater capacity of the lower portion of the pouch.12 Furthermore, this technique (in the Milan
Skin-reducing mastectomy with breast reconstruction and sub-pectoral implants
Figure 6 Early postoperative appearance after right skinreducing mastectomy with immediate reconstruction (500 cc Expander) and simultaneous left breast reduction.
series) allowed the use of larger breast prostheses (medium volume 432 ml), which would otherwise be difficult to accommodate within a conventional subpectoral pocket. At our own institution, the decision was taken to use permanent round Becker expanders (25% or 50%). These offered the potential advantages of (1) allowing a degree of flexibility in selecting the final volume of the reconstructed breast (taking account of the patient’s wishes); and (2) reducing the initial tension on the skin flaps and minimising the chance of flap necrosis without compromising the final volume attained. In a series of inverted ‘T’ mastectomies, relatively high rates of complications (up to 27%), most commonly involving problems of skin viability at the inverted ‘T’ junction were reported.9,13 Among the 10 women (18 procedures) reported here, only one woman (10% of all patients and 5.5% of all procedures) required removal of the expander owing to complications of haematoma and infection. Nava et al., in Milan,2 found that one-fifth (20%) of patients suffered severe complications, with an implant failure rate of 13%. These problems were significantly more frequent in heavy smokers for whom the sustained
1307
Figure 8 Postoperative view after change of expanders with silicone implants.
viability of thinner and longer flaps is less certain. Of note, three-quarters of cases requiring implant removal occurred in women smoking more than 20 cigarettes per day. The higher incidence of implant failure in the Milan series may be attributable to the use of fixed volume implants rather than tissue expanders, which allow gradual expansion according to the condition of the skin flaps. There tends to be excess pouch volume relative to skin envelope, the latter has been reduced whereas the former enhanced in size. The skin flaps need time to adjust and recover without undue tension caused by an underlying implant. An expander allows for this phased increase in skin tension, and is less likely to be associated with skin necrosis. Figures 6e8 show the favourable cosmetic results achievable with this technique of skin-reducing mastectomy. Levels of satisfaction were high among both clinicians and patients, particularly with the contour of the breast and degree of ptosis. It is unknown whether this form of reconstruction is compatible with postoperative chest wall irradiation. However, as the implant is well covered, this should help reduce the main sequelae of radiotherapy, such as capsular contracture. One of the women had received prior breast irradiation after initial breastconservation surgery for invasive malignancy, with no adverse effect on the cosmetic result to date. In conclusion, SRM is a good technique for implant-only breast reconstruction in women with large breasts who do not require postoperative radiotherapy. We would recommend the use of permanent tissue expanders in preference to fixed volume silicone implants as this, in our experience, has a low incidence of complications and provides good subjective cosmetic results.
References
Figure 7 Postoperative view after therapeutic left mastectomy and contra-lateral prophylactic mastectomy.
1. Bostwick J, editor. Total mastectomy with breast skin and volume reduction using an inverted ‘T’ incision. Plastic and reconstructive breast surgery. St Louis: Quality Medical Publisher Inc; 1990. p. 1048e54. 2. Nava M, Cortinovis U, Ottolenghi J, et al. Skin reducing mastectomy. Plast Reconstr Surg 2006;118:603e10. 3. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg 1991;87:1048e53.
1308 4. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg 1998;102:49e62. 5. Rivadeneira DE, Simmons RM, Fish SK, et al. Skinsparing mastectomy with immediate breast reconstruction: a critical analysis of local recurrence. Cancer J 2000;6: 331e5. 6. Kroll SS, Khoo A, Singletary SE. Local recurrence risk after skinsparing and conventional mastectomy: a 6-year follow-up. Plast Reconstr Surg 1999;104:421e5. 7. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol 1999; 6:676e81. 8. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and
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immediate breast reconstruction for invasive breast cancer. Ann Surg 2002;235:814e9. Carlson GW, Bostwick 3rd J, Styblo TM, et al. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 1997;225:570e5. Querci della Rovere G, Benson JR, Breach N, Nava M, editors. Oncoplastic and reconstructive surgery of the breast. London: Taylor and Francis Group; 2004. p. 21e31. Hammond DC, Capraro PA, Ozolins EB, et al. Use of a skin-sparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg 2002;110:206e11. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg 1998;102:1034e45. Hudson DA, Skoll PJ. Single Stage autologus breast restoration. Plast Reconstr Surg 2001;108:1163e71.