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Skin-sparing mastectomy: A novel method to maximise training opportunities
t h e s u r g e o n 8 ( 2 0 1 0 ) 2 9 3 e2 9 5
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Surgical Technique
Skin-sparing mastectomy: A novel method to maximise training opportunities
Keywords Breast cancer Mastectomy Surgical training
sir, Skin-sparing mastectomy (SSM) is an increasingly used technique both in the treatment of breast cancer and in prophylactic surgery.1 This technique involves a standard mastectomy with or without resection of the nipple-areola complex (NAC). The significant difference is the majority of the native skin envelope is preserved during the resection allowing immediate reconstruction with favourable cosmetic results. The exposure of the tissue during the operation is markedly limited, where just a single circum-areolar incision has been made. A reliable technique is necessary to achieve oncological clearance, avoid local recurrence and reduce postoperative complications. In particular, the incidence of skin flap necrosis can occur in up to 25% which can have devastating implications when implants have been used.2 Importantly, the incidence of complications may correlate with surgical experience.3 It is therefore essential that trainees have adequate opportunities to train in SSM. We describe a novel method which allows trainees to perform an SSM in patients already undergoing a conventional mastectomy. In this case study, a 64 year old lady was diagnosed with a left sided multifocal carcinoma. The patient was seen by the multidisciplinary team including a clinical psychologist and elected to undergo a left mastectomy and a prophylactic contralateral mastectomy based on personal concerns. During pre-admission she was counselled and consented for an SSM dissection prior to the completion of the procedure in the manner of a conventional mastectomy. Once anaesthetised, the trainee outlined the NAC and also marked the standard mastectomy flaps in indelible ink (Fig. 1). The border of the NAC was incised and while assisted by the trainer the operating surgeon performed an SSM initially by raising the skin flaps at the appropriate thickness (Fig. 2A). The SSM was completed by separating the breast from the underlying pectoral fascia (Fig. 2B). Once completed, the breast and NAC
Fig. 1 e The nipple-areola complex and the margins of the mastectomy were marked (A) and skin incisions made (B).
294
t h e s u r g e o n 8 ( 2 0 1 0 ) 2 9 3 e2 9 5
Fig. 2 e A subcutaneous mastectomy was performed (A) and the margins extended to the chest wall (B).
were correctly orientated with the skin envelope with interrupted silk sutures to facilitate adequate pathological assessment (Fig. 3A). The redundant mastectomy flap skin was then excised by incising the previously marked out elliptical mastectomy skin makings to complete the procedure as for a standard mastectomy (Fig. 3B). The removed specimen was then closely examined to assess the skin flap, in particular to identify uniformity, areas of exposed dermis and ‘button-holing’, and absence of visible glandular tissue on the skin side of SSM skin flaps. The contralateral prophylactic mastectomy was carried out in a conventional manner simultaneously. In this case, the final histology from the left breast showed foci of invasive disease and ductal carcinoma in situ (DCIS) with clear margins. The two sentinel lymph nodes did not demonstrate metastases. Importantly, the histological evaluation of the specimen was not affected by the SSM dissection. At follow-up the wounds healed satisfactorily and the cosmetic result, as judged by the patient, was no different when compared to the contralateral side. This is a novel but simple training adjunct which permits the trainee to perform a technically demanding procedure under close supervision. In addition, this technique can be
Fig. 3 e The nipple-areola complex was orientated (A) and a completion mastectomy performed (B).
scored as part of a procedure-based assessment for trainees (Table 1). It may however increase operative time; the side of the SSM took 50% longer than the standard mastectomy side.
Table 1 e Procedure-based assessment of SSM. Pre-procedure
Benefits Vs Risks Consent
Intra-operative
Positioning Marking Skin incision Skin flap retraction Scalpel dissection Uniformity of flap thickness Haemostasis Damage to deep dermal plexus/dermis exposure/buttonholing Remove breast to normal anatomical boundary and preserve inframammary fold Completion mastectomy
Assessment of specimen
Any visible remnant of glandular tissue on flap Exposure of dermis Evidence of diathermy injury on external side
t h e s u r g e o n 8 ( 2 0 1 0 ) 2 9 3 e2 9 5
SSM is an index procedure for a breast or plastic surgical trainee. In the UK, the National Breast Oncoplastic posts have tried to address similar training issues related to specialist breast reconstruction, but there a limited number of such posts. With the introduction of the ‘European Working Time Directive’ there is even less opportunity for formal operative experience and hence increased demands on surgical training.4 The reduced hours and operative experience has reaffirmed a need to develop training models and techniques that are increasingly innovative and allow for development of surgical skills. Simulators, animal and cadaveric courses try to achieve this in certain surgical specialities.5 However, no satisfactory similar opportunity exists in breast surgical training. Innovative and novel training techniques, such as the one described here, need to be developed to ensure future trainees can provide a safe and high quality service.
295
3. Garwood ER, Moore D, Ewing C, Hwang ES, Alvarado M, Foster RD, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann. Surg. 2009;249(1):26e32. 4. Morris-Stiff G, Sarasin S, Edwards P, Lewis W, Lewis M. The European working time directive: one for all and all for one? Surgery 2005;137(3):293e7. 5. Kneebone R. Simulation in surgical training: educational issues and practical implications. Med. Educ. 2003;37: 267e77.
Ravinder S. Vohra*, Shireen McKenzie, E. Philip L. Turton, Kieran J. Horgan, Raj Achuthan The Breast Unit, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK *Corresponding author. Tel.: þ44 113 392 5132; fax: þ44 113 392 8150. E-mail address: [email protected] (R.S. Vohra)
references
1. Carlson GW. Skin-sparing mastectomy. Operative Techniques in Plastic and Reconstructive Surgery 1999;6(1):2e6. 2. Hultman CS, Daiza S. Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome. Ann. Plast. Surg. 2003;50(3):249e55.
1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.05.005
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Correspondence: Surgical Technique
Skin-sparing mastectomy: A novel method to maximise training opportunities
Keywords Breast cancer Mastectomy Surgical training
sir, Skin-sparing mastectomy (SSM) is an increasingly used technique both in the treatment of breast cancer and in prophylactic surgery.1 This technique involves a standard mastectomy with or without resection of the nipple-areola complex (NAC). The significant difference is the majority of the native skin envelope is preserved during the resection allowing immediate reconstruction with favourable cosmetic results. The exposure of the tissue during the operation is markedly limited, where just a single circum-areolar incision has been made. A reliable technique is necessary to achieve oncological clearance, avoid local recurrence and reduce postoperative complications. In particular, the incidence of skin flap necrosis can occur in up to 25% which can have devastating implications when implants have been used.2 Importantly, the incidence of complications may correlate with surgical experience.3 It is therefore essential that trainees have adequate opportunities to train in SSM. We describe a novel method which allows trainees to perform an SSM in patients already undergoing a conventional mastectomy. In this case study, a 64 year old lady was diagnosed with a left sided multifocal carcinoma. The patient was seen by the multidisciplinary team including a clinical psychologist and elected to undergo a left mastectomy and a prophylactic contralateral mastectomy based on personal concerns. During pre-admission she was counselled and consented for an SSM dissection prior to the completion of the procedure in the manner of a conventional mastectomy. Once anaesthetised, the trainee outlined the NAC and also marked the standard mastectomy flaps in indelible ink (Fig. 1). The border of the NAC was incised and while assisted by the trainer the operating surgeon performed an SSM initially by raising the skin flaps at the appropriate thickness (Fig. 2A). The SSM was completed by separating the breast from the underlying pectoral fascia (Fig. 2B). Once completed, the breast and NAC
Fig. 1 e The nipple-areola complex and the margins of the mastectomy were marked (A) and skin incisions made (B).
294
t h e s u r g e o n 8 ( 2 0 1 0 ) 2 9 3 e2 9 5
Fig. 2 e A subcutaneous mastectomy was performed (A) and the margins extended to the chest wall (B).
were correctly orientated with the skin envelope with interrupted silk sutures to facilitate adequate pathological assessment (Fig. 3A). The redundant mastectomy flap skin was then excised by incising the previously marked out elliptical mastectomy skin makings to complete the procedure as for a standard mastectomy (Fig. 3B). The removed specimen was then closely examined to assess the skin flap, in particular to identify uniformity, areas of exposed dermis and ‘button-holing’, and absence of visible glandular tissue on the skin side of SSM skin flaps. The contralateral prophylactic mastectomy was carried out in a conventional manner simultaneously. In this case, the final histology from the left breast showed foci of invasive disease and ductal carcinoma in situ (DCIS) with clear margins. The two sentinel lymph nodes did not demonstrate metastases. Importantly, the histological evaluation of the specimen was not affected by the SSM dissection. At follow-up the wounds healed satisfactorily and the cosmetic result, as judged by the patient, was no different when compared to the contralateral side. This is a novel but simple training adjunct which permits the trainee to perform a technically demanding procedure under close supervision. In addition, this technique can be
Fig. 3 e The nipple-areola complex was orientated (A) and a completion mastectomy performed (B).
scored as part of a procedure-based assessment for trainees (Table 1). It may however increase operative time; the side of the SSM took 50% longer than the standard mastectomy side.
Table 1 e Procedure-based assessment of SSM. Pre-procedure
Benefits Vs Risks Consent
Intra-operative
Positioning Marking Skin incision Skin flap retraction Scalpel dissection Uniformity of flap thickness Haemostasis Damage to deep dermal plexus/dermis exposure/buttonholing Remove breast to normal anatomical boundary and preserve inframammary fold Completion mastectomy
Assessment of specimen
Any visible remnant of glandular tissue on flap Exposure of dermis Evidence of diathermy injury on external side
t h e s u r g e o n 8 ( 2 0 1 0 ) 2 9 3 e2 9 5
SSM is an index procedure for a breast or plastic surgical trainee. In the UK, the National Breast Oncoplastic posts have tried to address similar training issues related to specialist breast reconstruction, but there a limited number of such posts. With the introduction of the ‘European Working Time Directive’ there is even less opportunity for formal operative experience and hence increased demands on surgical training.4 The reduced hours and operative experience has reaffirmed a need to develop training models and techniques that are increasingly innovative and allow for development of surgical skills. Simulators, animal and cadaveric courses try to achieve this in certain surgical specialities.5 However, no satisfactory similar opportunity exists in breast surgical training. Innovative and novel training techniques, such as the one described here, need to be developed to ensure future trainees can provide a safe and high quality service.
295
3. Garwood ER, Moore D, Ewing C, Hwang ES, Alvarado M, Foster RD, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann. Surg. 2009;249(1):26e32. 4. Morris-Stiff G, Sarasin S, Edwards P, Lewis W, Lewis M. The European working time directive: one for all and all for one? Surgery 2005;137(3):293e7. 5. Kneebone R. Simulation in surgical training: educational issues and practical implications. Med. Educ. 2003;37: 267e77.
Ravinder S. Vohra*, Shireen McKenzie, E. Philip L. Turton, Kieran J. Horgan, Raj Achuthan The Breast Unit, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK *Corresponding author. Tel.: þ44 113 392 5132; fax: þ44 113 392 8150. E-mail address: [email protected] (R.S. Vohra)
references
1. Carlson GW. Skin-sparing mastectomy. Operative Techniques in Plastic and Reconstructive Surgery 1999;6(1):2e6. 2. Hultman CS, Daiza S. Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome. Ann. Plast. Surg. 2003;50(3):249e55.
1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.05.005