Skin-sparing mastectomy

Abstract

The surgical treatment of breast cancer has evolved rapidly in recent decades. Conservative treatment was adopted in the late 1970s, with rates above 70%, and this was followed by a period during which the indications for surgical intervention were expanded to those patients at high risk for BRCA1, BRCA2 mutations, and also due to new staging standards and use of nuclear magnetic resonance. This increase in the indications for mastectomy coincided with the availability of immediate breast reconstruction as an oncologically safe and important surgical procedure for prevention of sequelae. Immediate reconstruction was first aimed at correcting the consequences of treatment, and almost immediately, the challenge of the technique became the achievement of a satisfactory breast appearance and shape, as well as normal consistency. The skin-sparing mastectomy (SSM) in conservation first and nipple-areola complex (NAC) later was a result of this shift that occurred from the early 1990s to the present. The objective of this review is to present all these developments specifically in relation to SSM and analyze our personal experience as well as the experience of surgeons worldwide with an emphasis on the fundamental aspects, indications, surgical technique, complications, oncological safety, and cosmetic results of this procedure.

Keywords: Breast cancer; oncologic breast surgery; oncoplastic breast surgery; skin-sparing mastectomy (SSM).

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1

Evolution of the procedures (I) that generated the skin sparing mastectomy. SSM, skin-sparing mastectomy.

Figure 2

Evolution of the procedures (II) of the SSM to Nipple Sparing Mastectomies (risk reduction and therapeutic). SSM, skin-sparing mastectomy; NSM, nipple sparing mastectomy; ASM, areola sparing mastectomy; ELIOT, intraoperative radiotherapy with electrons.

Figure 3

Skin sparing mastectomies. Classification: (A,B) Incision type I; (C) incision type II; (D) incision type III; (E) incision type IV; (F) incision type IV.

Figure 4

(A) Skin sparing mastectomy design; (B,C) dissection of the flaps in the plane of the superficialis fascia. Careful management of mastectomy flap to prevent vascular complications.

Figure 5

Anatomical variations of the mastectomy flaps in the presence surface sheet—superficialis fascia (CS/FS) or absence and location of the mammary gland in relation to the dermis (19).

Figure 6

Skin-sparing mastectomy type I (periareolar) and axillary dissection. (A) Conservation of cutaneous pocket and the submammary fold, preserving the anatomical limits; (B) mastectomy and axillary dissection specimen.

Figure 7

Skin-sparing mastectomy type I (periareolar) and sentinel node biopsy through the same incision detected by Gamaprobe. Excision of skin percutaneous biopsy scar.

Figure 8

Skin-sparing mastectomy with suspicious microcalcifications near the dermis (Mammogram). Mastectomy specimen stained with ink. Margins were insufficient in the frozen section. Bottom-right: extension of cutaneous resection.

Figure 9

Skin-sparing mastectomy and reconstruction with expander. Prevention of complications. A complete muscle dissection pocket covering the implant in its entirety. The risk of extrusion and loss of the prosthesis to a possible skin necrosis decreases.

Figure 10

Skin-sparing mastectomy and reconstruction with expander. Prevention of complications. Dissection of the pectoralis major muscle and realization of a full pocket coverage of the expander, with the help of a mesh of silk. Outcome at 1 month after surgery.

Figure 11

Skin-sparing mastectomy and reconstruction with free tram flap in a local recurrence of conservative treatment. Patient irradiated and smoking. Extensive skin necrosis. Local expectation and toilette. Autoshaping sequel and secondary scar correction. Final result.

Figure 12

Skin-sparing mastectomy type II axillary dissection, and immediate breast reconstruction with anatomical expander. Top right: planning the second time to change expander for definitive prosthesis and reduction of the opposite breast. Down: satisfactory end result, then the reconstruction of the nipple and areola tattoo.

Figure 13

Skin-sparing mastectomy and reconstruction with extended latissimus dorsi flap. Local recurrence of conservative treatment in an irradiated breast. Bottom left five zones of adipose tissue that will rotate back with the flap to give volume is. Final result. Good result of the reconstructed breast and symmetry.

Figure 14

Skin-sparing mastectomy type I and free tram flap reconstruction. Immediate and mediate result. Final result after reconstruction of the NAC. Good result of the reconstructed breast and symmetry. NAC, nipple-areola complex.

Figure 15

(A,B) Skin-sparing mastectomy and reconstruction with latissimus dorsi flap to repair the central cutaneous defect, and definitive expander placement to replace the volume; (C) reconstruction ended after reconstruction of the NAC; (D) good result of the reconstructed breast and symmetry. NAC, nipple-areola complex.