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Review Article
Technical Advances in Skin Sparing Mastectomy
Grant W. Carlson1, 2
1 Division
2 Winship
1. Introduction
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. Coopers 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 dissection kept as close to it as run a risk of
skin slough [12].
Beer et al. examined breast tissue from 62 reduction
specimens for the presence of the superficial fascia [13]. They
found the superficial fascia was absent in 44% of the inferior
breast quadrants examined. When it was present, no breast
tissue was found beyond it. Torresan et al. studied the skin
that would have been preserved in SSM in 42 mastectomy
specimens [14]. They found that the presence of breast
tissue was significantly associated with skin flaps thicker than
5 mm. They found no correlation between the presence of
Type II
(a)
(b)
Type IV
Type III
(c)
(d)
breast tissue in the skin flaps and age, body mass index, or
menopausal status. Hicken outlined the extent of mammary
tissue in 1940 by injecting X-ray contrast material into the
lactiferous ducts of 385 mastectomy specimens [15]. He
found that in 95% of cases the ducts ascended into the axilla,
15% passed into the epigastric space, and 2% followed the
lateral chest wall beyond the anterior border of the latissimus
dorsi muscle. This study defined the classic boundaries of
a mastectomy: the clavicle, rectus sheath, midline of the
sternum, and the anterior border of the latissimus dorsi
muscle.
(a)
(b)
(a)
(b)
(c)
(d)
(e)
Figure 4: (a) Intraoperative photograph showing Wise pattern incisions with de-epithelialization of the skin. The area in yellow will be
resected as part of the Type IV SSM. This excision leaves a rim of dermis along the vertical limbs of the skin excision. (b) The inferior skin
flap is elevated down to the inframammary fold. (c) The de-epithelialized inferior skin flap is draped over the tissue expander and sutured
to the released inferior border of the pectoralis major muscle. Back cuts are made to allow inset of the dermal flap. (d) The skin flaps just
prior to closure. The de-epithelialized vertical limbs serve as a buttress. (e) Preoperative appearance. (f) Postoperative appearance after type
IV SSM and implant reconstruction using an inferior dermal flap.
(a)
Table 1: Series of Type IV skin sparing mastectomy using an inferior dermal flap.
Author
12
30
20
34
(c)
Factor
SSM Type
Type I
Type II
Type III
Type IV
Tobacco
Radiation
Overall
Total N (%)
232 (36.7)
293 (46.2)
40 (6.3)
68 (10.8)
79 (12.5)
21 (3.3)
633 (100)
22 (9.5)
28 (13)
10 (25)
18 (26.5)
16 (20.3)
5 (23.8)
88 (13.9)
6. Summary
The use of skin sparing mastectomy has been one of the
greatest advancements in immediate breast reconstruction
in the last two decades. It is technically more challenging
than traditional mastectomy and requires close coordination
between the oncologic and reconstructive surgeons. Proper
patient selection and meticulous technique are necessary to
avoid wound complications.
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. 570578, 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.
10481053, 1991.
[3] G. W. Carlson, Skin sparing mastectomy: anatomic and
technical considerations, American Surgeon, vol. 62, no. 2, pp.
151155, 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.
902905, 2008.
[5] S. S. Kroll, A. Khoo, S. Eva et al., Local recurrence risk after
skin-sparing and conventional mastectomy: a 6-year followup, 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. 632639, 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. 620626, 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. 676681, 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. 23162321, 2003.
[10] W. J. Sotheran and R. M. Rainsbury, Skin-sparing mastectomy in the UKa review of current practice, Annals of the
Royal College of Surgeons of England, vol. 86, no. 2, pp. 8286,
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 skinsparing mastectomy, Cancer, vol. 94, no. 6, pp. 16191625,
2002.
[31]
[32]
[33]
[34]
[35]
[36]
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