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
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