Skin sparing mastectomy has resulted in marked improvement in the aesthetic results of immediate breast reconstruction. Mature data has confirmed its oncological safety in the treatment of breast cancer. The procedure has gained wide acceptance and has undergone numerous technical advances since its introduction over twenty years ago. Careful patient selection and choice of skin incisions are necessary to avoid complications. 1. Introduction The term skin sparing mastectomy (SSM) was first used by Toth and Lappert in 1991 [2]. They described preoperative planning of mastectomy incisions in an attempt to maximize skin preservation and facilitate immediate breast reconstruction (IBR). The procedure removes the breast, nipple-areola complex, previous biopsy incisions, and skin overlying superficial tumors [3]. Preservation of the inframammary fold (IMF) and native skin greatly enhances the aesthetic result of breast reconstruction. The operation has been adopted for patients with early breast cancer treated by total mastectomy and immediate reconstruction but has not gained universal acceptance. Most surgeons surveyed agree that the procedure improves the cosmetic results of immediate breast reconstruction [4]. Despite numerous studies that have demonstrated the oncological safety of the procedure compared to traditional total mastectomy, there are still concerns about the oncological safety [1, 5–9]. One international survey of over 1,000 surgeons found that 78% of respondents believed that the current published literature demonstrated that SSM does not result in higher local recurrence rates of breast cancer, 25% did not believe the data [9]. Despite these concerns, the utilization of skin sparing mastectomy continues to increase [10]. 2. Completeness of Mastectomy The breast is a modified cutaneous gland or “skin appendage”. It is enclosed between the superficial and deep layers of the superficial fascia of the anterior abdominal wall. The superficial layer is a very delicate but definite structure. Large axial vessels lie deep to this plane and send vertical branches to the subdermal plexus. This layer allows the surgeon to dissect the skin flaps in a relatively avascular plane and include minimal mammary tissue. Cooper’s “ligaments” are peripheral projections of breast tissue in fibrous processes, which fuse with the superficial layer of the superficial fascia [11]. Skiles demonstrated that these projections were intimately associated with the skin and concluded in order to excise the whole breast that a large amount of skin need be sacrificed or the
References
[1]
G. W. Carlson, J. Bostwick, T. M. Styblo et al., “Skin-sparing mastectomy: oncologic and reconstructive considerations,” Annals of Surgery, vol. 225, no. 5, pp. 570–578, 1997.
[2]
B. A. Toth and P. Lappert, “Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning,” Plastic and Reconstructive Surgery, vol. 87, no. 6, pp. 1048–1053, 1991.
[3]
G. W. Carlson, “Skin sparing mastectomy: anatomic and technical considerations,” American Surgeon, vol. 62, no. 2, pp. 151–155, 1996.
[4]
J. Shen, J. Ellenhorn, D. Qian, D. Kulber, and J. Aronowitz, “Skin-sparing mastectomy: a survey based approach to defining standard of care,” American Surgeon, vol. 74, no. 10, pp. 902–905, 2008.
[5]
S. S. Kroll, A. Khoo, S. Eva, et al., “Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up,” Plastic and Reconstructive Surgery, vol. 104, no. 2, pp. 421–425, 1999.
[6]
S. Lanitis, P. P. Tekkis, G. Sgourakis, N. Dimopoulos, R. Al Mufti, and D. J. Hadjiminas, “Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies,” Annals of Surgery, vol. 251, no. 4, pp. 632–639, 2010.
[7]
L. A. Newman, H. M. Kuerer, K. K. Hunt et al., “Presentation, treatment, and outcome of local recurrence after skin- sparing mastectomy and immediate breast reconstruction,” Annals of Surgical Oncology, vol. 5, no. 7, pp. 620–626, 1998.
[8]
R. M. Simmons, S. K. Fish, L. Gayle et al., “Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies,” Annals of Surgical Oncology, vol. 6, no. 7, pp. 676–681, 1999.
[9]
R. J. Bleicher, N. M. Hansen, and A. E. Giuliano, “Skin-sparing mastectomy. specialty bias and worldwide lack of consensus,” Cancer, vol. 98, no. 11, pp. 2316–2321, 2003.
[10]
W. J. Sotheran and R. M. Rainsbury, “Skin-sparing mastectomy in the UK—a review of current practice,” Annals of the Royal College of Surgeons of England, vol. 86, no. 2, pp. 82–86, 2004.
[11]
A. Cooper, On the Anatomy of the Breast, Longmans, London, UK, 1840.
[12]
H. Skiles, “Contributions to the surgical anatomy of the breast,” Edinburgh Medical Journal, vol. 37, p. 1099, 1892.
[13]
G. M. Beer, Z. Varga, S. Budi, B. Seifert, and V. E. Meyer, “Incidence of the superficial fascia and its relevance in skin-sparing mastectomy,” Cancer, vol. 94, no. 6, pp. 1619–1625, 2002.
[14]
R. Z. Torresan, C. C. D. Santos, H. Okamura, and M. Alvarenga, “Evaluation of residual glandular tissue after skin-sparing mastectomies,” Annals of Surgical Oncology, vol. 12, no. 12, pp. 1037–1044, 2005.
[15]
N. F. Hicken, “Mastectomy: a clinical pathologic study demonstrating why most mastectomies result in incomplete removal of the mammary gland,” Archives of Surgery, vol. 40, pp. 6–14, 1940.
[16]
T. E. Lockwood, “Superficial fascial system (SFS) of the trunk and extremities: a new concept,” Plastic and Reconstructive Surgery, vol. 87, no. 6, pp. 1009–1018, 1991.
[17]
D. Garnier, R. Angonin, P. Foulon, J. P. Chavoin, B. Ricbourg, and M. Costagliola, “Le sillon sous-mammaire: mythe ou re'alite'?” Annales de Chirurgie Plastique et Esthetique, vol. 36, no. 4, pp. 313–319, 1991.
[18]
C. D. Haagenson, Disease of the Breast, W.B. Saunders, Philadelphia, Pa, USA, 2nd edition, 1971.
[19]
G. W. Carlson, N. Grossl, M. M. Lewis, J. R. Temple, and T. M. Styblo, “Preservation of the inframammary fold: what are we leaving behind?” Plastic and Reconstructive Surgery, vol. 98, no. 3, pp. 203–210, 1996.
[20]
B. A. Toth and S. P. Daane, “Purse-string mastectomy with immediate prosthetic reconstruction: an improved skin-sparing technique for small breasts,” Plastic and Reconstructive Surgery, vol. 111, no. 7, pp. 2333–2337, 2003.
[21]
P. J. Skoll and D. A. Hudson, “Skin-sparing mastectomy using a modified wise pattern,” Plastic and Reconstructive Surgery, vol. 110, no. 1, pp. 214–217, 2002.
[22]
J. Bostwick, “Total mastectomy with breast skin and volume reduction using an inverted T incision,” in Plastic and Reconstructive Breast Surgery, pp. 1048–1054, Quality Medical Publishing, St. Louis, Mo, USA, 1990.
[23]
A. Shoher, R. Hekier, and A. Lucci Jr., “Mastectomy performed with scissors following tumescent solution injection,” Journal of Surgical Oncology, vol. 83, no. 3, pp. 191–193, 2003.
[24]
J. B. McCraw, B. Myers, and K. D. Shanklin, “The value of fluorescein in predicting the viability of arterialized flaps,” Plastic and Reconstructive Surgery, vol. 60, no. 5, pp. 710–719, 1977.
[25]
M. I. Newman, M. C. Samson, J. F. Tamburrino, and K. A. Swartz, “Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction,” Journal of Reconstructive Microsurgery, vol. 26, no. 7, pp. 487–492, 2010.
[26]
T. J. Meretoja, S. Rasia, K. A. J. Von Smitten, S. L. Asko-Seljavaara, H. O. M. Kuokkanen, and T. A. Jahkola, “Late results of skin-sparing mastectomy followed by immediate breast reconstruction,” British Journal of Surgery, vol. 94, no. 10, pp. 1220–1225, 2007.
[27]
S. A. Slavin, S. J. Schnitt, R. B. Duda et al., “Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer,” Plastic and Reconstructive Surgery, vol. 102, no. 1, pp. 49–62, 1998.
[28]
G. W. Carlson, T. M. Styblo, R. H. Lyles et al., “The use of skin sparing mastectomy in the treatment of breast cancer: the Emory experience,” Surgical Oncology, vol. 12, no. 4, pp. 265–269, 2003.
[29]
Y. S. Chun, K. Verma, H. Rosen et al., “Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction,” American Journal of Surgery, vol. 201, no. 2, pp. 160–165, 2011.
[30]
K. Davies, L. Allan, P. Roblin, D. Ross, and J. Farhadi, “Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction,” Breast, vol. 20, no. 1, pp. 21–25, 2011.
[31]
C. S. Hultman, S. Daiza, and L. T. Furlow, “Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome,” Annals of Plastic Surgery, vol. 50, no. 3, pp. 249–255, 2003.
[32]
A. K. Antony, B. M. Mehrara, C. M. McCarthy et al., “Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion,” Plastic and Reconstructive Surgery, vol. 124, no. 2, pp. 356–363, 2009.
[33]
D. C. Hammond, P. A. Capraro, E. B. Ozolins, and J. F. Arnold, “Use of a skin-sparing reduction pattern to create a combination skin-muscle flap pocket in immediate breast reconstruction,” Plastic and Reconstructive Surgery, vol. 110, no. 1, pp. 206–211, 2002.
[34]
M. B. Nava, U. Cortinovis, J. Ottolenghi et al., “Skin-reducing mastectomy,” Plastic and Reconstructive Surgery, vol. 118, no. 3, pp. 603–610, 2006.
[35]
C. A. Derderian, N. S. Karp, and M. Choi, “Wise-pattern breast reconstruction: modification using alloderm and a vascularized dermal-subcutaneous pedicle,” Annals of Plastic Surgery, vol. 62, no. 5, pp. 528–532, 2009.
[36]
A. Losken, B. Collins, and G. W. Carlson, “Dual plane prosthetic reconstruction using the modified wise pattern mastectomy and fasciocutaneous flap in women with macromastia,” Plastic and Reconstructive Surgery, vol. 126, no. 3, pp. 731–738, 2010.
