Optimizing the total skin-sparing mastectomy

Akushla Wijayanayagam, Anjali S Kumar, Robert D Foster, Laura J Esserman
Archives of Surgery 2008, 143 (1): 38-45; discussion 45

HYPOTHESIS: Dissection of subnipple tissue to spare the entire skin envelope of the breast (total skin-sparing mastectomy) is a feasible option in appropriately selected patients and yields an excellent final cosmetic outcome.

DESIGN: Prospective surgical technique outcomes study.

SETTING: University-based breast care referral center.

PATIENTS: Total skin-sparing mastectomy with preservation of the nipple-areola complex was performed in 64 breasts in 43 women. Indications for total skin-sparing mastectomy included prophylaxis (n = 29), invasive carcinoma (n = 24), and ductal carcinoma in situ (n = 11).

INTERVENTIONS: Preoperative magnetic resonance imaging was used to select patients and to confirm absence of disease within 2 cm of the nipple. Nipple tissue was serially sectioned at pathologic analysis. Circumareolar/nipple-areola free graft, inframammary, crescentic mastopexy, areola crossing, and radial incisions were used. Immediate reconstruction was performed with implant or tissue expander placement or latissimus dorsi muscle, transverse rectus abdominis muscle, or deep inferior epigastric perforator muscle flaps.

MAIN OUTCOME MEASURES: Nipple-areola complex skin survival, implant loss, skin flap necrosis, wound infection, and occult neoplasm.

RESULTS: Nipple-areola complex skin survival was complete in 80% of patients (n = 51) and partial in 16% (n = 10); it was highest with the radial incision at 97% survival (n = 34). Occult ductal carcinoma in situ in the nipple-areola complex was found in 2 patients (3%), and the affected nipple-areola complex was subsequently removed. Other complications included implant loss, total skin-sparing skin flap necrosis, and infection. Although follow-up is limited, no patients have exhibited cancer recurrence.

CONCLUSIONS: Total skin-sparing mastectomy is a viable surgical option in selected patients with breast neoplasm and those who choose prophylactic mastectomy, and may increase the willingness of women to consider mastectomy to reduce their risk of breast cancer.

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