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  • 1. Aesth Plast Surg (2010) 34:71–77 DOI 10.1007/s00266-009-9452-7 ORIGINAL ARTICLE Skin-Reducing Subcutaneous Mastectomy Using a Dermal Barrier Flap and Immediate Breast Reconstruction with an Implant: A New Surgical Design for Reconstruction of Early-Stage Breast Cancer Yalcin Bayram • Yalcin Kulahci • Ceyhun Irgil Murat Calikapan • Nurettin Noyan • Received: 19 May 2009 / Accepted: 19 November 2009 / Published online: 31 December 2009 Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009 Abstract Background The development of skin-sparing mastectomy techniques for early-stage breast cancer has opened a new era in reconstructive breast surgery. Because of improved early diagnoses, the demand for skin-sparing techniques continues to increase more than ever. Methods Between March 2006 and April 2008, skinreducing subcutaneous mastectomy (SRSM) using the dermal barrier flap technique and simultaneous breast reconstruction with silicone implants was performed for 15 patients (a total of 26 breasts) who had either a diagnosis of early-stage breast cancer or indications for prophylactic mastectomy. Of the 15 patients, 11 underwent bilateral reconstruction. The remaining four patients underwent unilateral reconstruction using SRSM with the dermal barrier flap technique. Results The average age of the patients who underwent SRSM with the dermal barrier flap was 45.7 years. All the patients were discharged from the hospital on postoperative day 1. The mean follow-up period was 12 months, and the recovery time was 35 days. Excellent aesthetic results and uneventful healing were obtained for 23 breasts. Partial nipple–areola necrosis occurred in two breasts. Total skin necrosis in the bilateral nipple–areola and central breast region occurred for one patient who underwent bilateral SRSM. Prosthesis exposure was not observed for any of these patients. Conclusions The authors present their early results with SRSM using the dermal barrier flap and silicone implants for early-stage breast cancer. The dermal barrier flap became a reliable procedure by providing a decreased breast envelope, eliminating the risk of implant exposure, and forming a double layer of dermal tissue at the incision line. This study presented at: 13th Turkish Society of Aesthetic Plastic Surgery Congress & ISAPS Course, 19–22 June 2009, Hilton Convention Center, Istanbul-Turkey. Keywords Dermal barrier flap Á Early-stage breast cancer Á Implant Á Skin-reducing subcutaneous mastectomy Y. Bayram Department of Plastic and Reconstructive Surgery, Bursa Military Hospital, Bursa, Turkey Y. Kulahci (&) Á N. Noyan Department of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy and Medical Faculty, Haydarpasa Training Hospital, Selimiye Mah. Tıbbiye Cad., Kadikoy, 34668 Istanbul, Turkey e-mail: yakulahci@yahoo.com C. Irgil Bursa Breast Surgery Clinic, Bursa, Turkey M. Calikapan Department of General Surgery, Bursa Oncology Hospital, Bursa, Turkey Breast cancer surgery has evolved from radical mastectomy, with excision of as much tissue as possible, to subcutaneous mastectomy, with sparing of as much tissue as possible. Notably, the choice of the procedure depends on both the location and the stage of the cancer. The development of diagnostic imaging techniques has increased the medical profession’s awareness of breast cancer and led to earlier diagnoses. Because a greater percentage of cancers are detected at earlier stages, the need for skin-sparing techniques has increased. Ongoing controversies continue to debate the issues of skin-sparing mastectomy and sparing of the nipple–areola complex. These controversies are focused 123
  • 2. 72 on problems of nipple–areola survival and the reliability of methods from an oncologic point of view. Many published reports describe the reliability of subcutaneous mastectomy under certain indications [1–6]. In earlystage breast cancer, immediate breast reconstruction after subcutaneous mastectomy is used with increasing frequency. Recently, prophylactic mastectomy has been performed for patients displaying the following oncologic risk factors: a positive family history, BRCA-1 and -2 gene mutation, atypic ductal hyperplasia, a history of skin cancer, intensive lobular carcinoma in situ, and ductal carcinoma in situ. Prophylactic mastectomy has been performed increasingly due to either patient demand or oncologic surgeon proposal [7–9]. Sparing of the nipple–areola complex is extremely important for aesthetic results and patient satisfaction in both early-stage breast cancer and high-risk groups [10]. Although subcutaneous mastectomy offers excellent cosmetic results with small breasts, obtaining optimum results for moderate-sized and large breasts is more challenging and requires repositioning of the areola as well as decreasing the breast skin surface area. Furthermore, problems with wound healing and jeopardized nipple– areola survival both exist with large breasts. Finally, exposure of the implant and failure of reconstruction often become inevitable. This report describes our early results with breast reconstruction using skin-reducing subcutaneous mastectomy (SRSM) and silicone implants for early-stage breast cancer. A dermal barrier flap has been designed to avoid problems with nipple–areola survival and wound healing of ptotic breasts. The flap has eliminated exposure of the implant during the use of excess skin. Aesth Plast Surg (2010) 34:71–77 Patient Selection All the patients who had moderate-sized ptotic breasts and no history of previous reduction mammoplasties underwent SRSM with a barrier dermal flap. Breast ultrasound was performed for all the patients, and mammography was performed for the patients older than 40 years according to the oncologic diagnostic criteria for those admitted to the center. Fine-needle aspiration biopsy was performed for suspicious lesions. The following subcutaneous mastectomy criteria were accepted as suitable oncologic criteria for SRSM: stage 1 or 2 (early-stage) cancer and mass with peripheral localization. Table 1 summarizes the demographic characteristics of the patients. All the patients were informed about the surgical procedure, the details of their breast disease, the risk factors of redundant breast tissue, and the possible advantages and disadvantages of the surgical technique. Prophylactic mastectomy was performed for a total of nine breasts in five patients at high risk. Four findings determinant of a high risk for breast cancer were accepted as criteria: positive family history, disease disseminated in the breast (mass or cyst), suspicious areas or calcifications shown by mammography, and diagnosed cancer in the opposite breast. If one or more of these criteria were present, the patient was informed about the relevant risks. We offer prophylactic mastectomy to the patients who have one or more of these criteria as well as an extreme fear of breast cancer [11–13]. Prophylactic SRSM with a dermal barrier flap and immediate breast reconstruction with implants was performed for the patients who accepted the operation. Preoperative Planning Materials and Methods Between March 2006 and April 2008, SRSM using the dermal barrier flap technique and simultaneous breast reconstruction with a silicone implant was performed for 15 patients (a total of 26 breasts) who had either a diagnosis of early-stage breast cancer or indications for prophylactic mastectomy at the Bursa Breast Surgery Clinic and the Bursa and Kayseri Military Hospital, Department of Plastic and Reconstructive Surgery. Of the 15 patients, 11 (73.3%) underwent bilateral reconstruction. The remaining four patients had high risks of breast cancer other than the diagnosed cancer in the opposite breast (fourth patient selection criteria) but did not agree to the procedure for the healthy breast. These four patients underwent unilateral reconstruction using the dermal barrier flap technique. 123 Operation planning was performed with patients in the standing position. First, the region of the mass nearest the skin was marked, followed by marking of the inframammary fold. As shown in Fig. 4a, a distance of 4 cm between the inframammary sulcus (IMS) and the nipple is the projectional distance on the sternum. On the breast, it becomes 5–7 cm. The distance from a to b in Fig. 1a is planned as 6 cm. At the beginning of planning, drawing the projection of the IMS on the sternum shows whether there is any vertical asymmetry with the thorax. Generally, 1–2 cm of asymmetry between the IMS and thorax is common. Showing this situation is helpful in planning to achieve postoperative symmetry. The new nipple projection is drawn 4 cm. above the IMS projection on the sternum. A horizontal line is drawn from this mark to the breast to determine the new nipple position. The distance between the new nipple
  • 3. Aesth Plast Surg (2010) 34:71–77 73 Table 1 Patient demographic data Patient no. Preoperative diagnosis Type of surgery No. of Prophylactic Complication breasts mastectomy (n) TNM classification/ pathologic diagnosis Oncologic treatment 1 Left breast ca Bilateral SRSM 2 TxN1M0 CT ? RT ? HT 2 Right breast ca Bilateral SRSM 3 Left breast ca 4 5 2 – 2 1 – T1N1M0 CT ? HT 1 – T1N2M0 CT ? RT ? HT Left breast ca Previous left SSM, 1 right SRSM Bilateral SRSM 2 1 – TisN0M0 – Left breast ca Bilateral SRSM 2 1 – T2N0M0 HT 6 Left breast ca Bilateral SRSM 2 1 Total nipple–areola T1N0M0 necrosis in two breasts CT ? HT 7 Right breast ca Bilateral SRSM 2 1 – T2N0M0 CT ? HT 8 Left breast ca Bilateral SRSM 2 1 – T1N0M0 HT 9 Left breast ca Bilateral SRSM 2 1 – T1N0M0 HT 10 Right breast ca Right SSM, left SRSM 1 1 – T2N0M0 CT ? HT 11 High risk Bilateral SRSM 2 2 Partial nipple– areola necrosis Normal breast tissue – 12 High risk Left SRSM 1 1 – Fibrocystic changing, – epithelial hyperplasia, adenosis 13 High risk Bilateral SRSM 2 2 – TisN0M0 – 14 High risk Bilateral SRSM 2 2 – DIN 1b HT 15 High risk Right SRSM 1 1 Partial nipple– areola necrosis Fibrocystic changing, ductal ectasia, sclerosing adenosis HT TNM tumor node metastasis, CT chemotherapy, RT radiotherapy, HT hormonotherapy, ca cancer, SRSM skin-reducing subcutaneous mastectomy, SSM skin-sparing mastectomy (performed elsewhere) Fig. 1 Schematic presentation of the surgical technique. a Preoperative incision planning. The area inside the planned incision is deepithelialized except for the nipple–areola. The lateral vertical incision is performed from line a to line b. The a–b distance is planned as 6 cm. b Final appearance. Deepithelialization of the dermal barrier flap without skin excision. Note the shaded areas marked behind the suture line, which represent the dermal barrier flap that has created an extra layer position and the sternal notch is measured to make both nipple distances equal. We marked the new position of the nipple–areola complex as 4 cm above the inframammary fold. Operation planning then was performed according to the superior pedicle reduction mammoplasty technique. To decrease tension in the suture line, our preparations left more skin intact than conventional breast reduction (Figs. 1, 2a–c, 3a, 123
  • 4. 74 Aesth Plast Surg (2010) 34:71–77 Fig. 2 A 55-year-old patient with a positive family history and suspicious microcalcification areas, as shown by mammography. The patient underwent bilateral prophylactic skin-reducing subcutaneous mastectomy (SRSM) due to a high risk for breast cancer. Pathologic diagnosis was reported as carcinoma in situ. a, b Preoperative planning for bilateral SRSM. c After completion of the planned skin incision, deepithelialization, and mastectomy, a close-up view of the barrier dermal flap and its thickness is seen. Subcutaneous mastectomy was performed from the lateral incision without skin excision. d–f Appearance of the patient 3 months postoperatively. g–i Appearance of the patient 2 years postoperatively and 4a). Using this technique, much more breast skin reduction was achieved, and the final scar was located at the inferior mammary sulcus. Operative Procedure The area between the marked incisions were deepithelialized except for the nipple–areola complex (diameter, 4– 4.5 cm). Total subcutaneous mastectomy was performed from the lateral vertical incision via a full incision (Figs. 1a and 2c). Cooper’s ligament, oncologically reliable and harmless for the subdermal plexus, was followed as a surgical plan during mastectomy. The pathologic specimen beneath the nipple–areola complex was marked. Axillary dissection was performed from the same incision when needed. Axillary lymph node dissection was performed for seven patients whose intraoperative sentinel lymph node biopsy results were positive. Dissection was not performed for three patients who had negative sentinel node results. All reconstructions were performed using CPG 323 Cohesive III, medium, and high-profile silicone gel-filled breast implants with a teardrop shape (Mentor, Canada). The nipple–areola complex was moved to the planned position, and the deepithelialized skin surrounding it was 123 sutured to its peripheral deepithelialized border. The dermal barrier flap, this deepithelialized area in the midinferior region, was moved laterally without folding, and the lateral and medial incisions were sutured to each other (Fig. 1b). Drains were inserted and left in place for about 10–14 days. Tight bandages and breast girdles were used for 4–6 weeks. Results The average age of patients who underwent SRSM was 45.7 years. All the patients were discharged from the hospital on postoperative day 1. For all the patients, 560– 890 g per breast was resected. No blood transfusions were required. The mean follow-up period was 12 months, and the recovery time was 35 days. For 23 breasts, excellent aesthetic results and uneventful healing were obtained with increased patient satisfaction (Figs. 2d–i, 3b–g, and 4b–e). Partial nipple–areola necrosis occurred in two breasts (7.7%). One implant was replaced with a smaller implant in one breast. Debridement and primary repair were performed for another breast in which partial necrosis developed. Total skin necrosis at the bilateral nipple–areola and
  • 5. Aesth Plast Surg (2010) 34:71–77 75 Fig. 3 A 44-year-old patient with a positive family history and suspicious microcalcification areas, as shown by mammography. This patient underwent bilateral prophylactic skin-reducing subcutaneous mastectomy (SRSM) due to a high risk for breast cancer. The pathologic diagnosis was reported as carcinoma in situ. a Preoperative planning. Note the asymmetry of the breasts. b–d Appearance of the patient 2 months postoperatively. e–g Appearance of the patient 2 years postoperatively Fig. 4 A 40-year-old patient who underwent bilateral prophylactic skin-reducing subcutaneous mastectomy (SRSM). a Appearance of the preoperative planning for the patient. The nipple–areola was planned as 4 cm superior to the inframammary sulcus. The 4-cm distance between the inframammary sulcus (IMS) and the nipple is the projectional distance on the sternum. On the breast, it becomes 5– 7 cm. The distance from a to b in Fig. 1a is planned to be 6 cm. The new nipple projection is drawn 4 cm above the IMS projection on the sternum. The distance between the new nipple position and the sternal notch is measured to make both nipple distances equal. b, c Appearance of the patient 4 months postoperatively. d, e Appearance of the patient 18 months postoperatively central breast region occurred for another patient who underwent bilateral SRSM (7.7%) (Table 1). Becker 35 prostheses were placed after debridement in patients who had bilateral total necrosis. Heavy smoking (1‘ pack/day for 15 years) was determined to be the etiology for this patient. Inflation of the prosthesis and reconstruction of the nipple–areola were obtained uneventfully in this case. There was no wound dehiscence at the vertical incision lines. Prosthesis exposure was not observed in either of these patients. 123
  • 6. 76 Positive axillary lymph node metastases were reported for three patients. The results of the pathologic investigations are demonstrated in Table 1. In the postoperative period, chemotherapy, radiotherapy, and hormonotherapy were administered to patients when needed (Table 1). For three patients, flushing, sensitivity, and edema were observed after chemotherapy in three breasts at the site where axillary dissection was performed. Recovery was obtained with palliative medical treatment for these patients. Discussion Confusion still exists about mastectomy procedure terminology. The term ‘‘subcutaneous mastectomy’’ was used to denote benign breast lesions for the first time by Freeman [14]. This term means excision of the breast gland and sparing of the nipple–areola. The term ‘‘skin-sparing mastectomy’’ was used for excisions of the breast gland, the nipple–areola, and biopsy scars for the first time by Toth and Lappert [15] in 1991. The term ‘‘skin-reducing mastectomy’’ was used for the first time by Nava et al. [16]. With this technique, the nipple–areola is not spared but either immediately reconstructed as a graft or later reconstructed with other methods. ‘‘Skin-sparing mastectomy with nipple–areola complex preservation’’ was the terminology preferred by Vlajcic et al. [6]. In the current study, we used the term ‘‘skin-reducing subcutaneous mastectomy’’ for the first time. This term means reduction of breast skin without skin excision while subcutaneous mastectomy is performed. Although subcutaneous mastectomy is a reliable method for patients who have early diagnosed peripheral tumors [5, 6, 17, 18], prophylactic mastectomy is performed for the opposite-side breast at the patient’s request. In addition, prophylactic mastectomy is performed for patients at high risk for breast cancer. Patients who have risk factors can be followed closely by clinical examinations, mammography, and magnetic resonance imaging when needed. It should be emphasized to the patients that although prophylactic mastectomy reduces their breast cancer risk, this technique does not eradicate risk altogether [12, 19]. In the current study, BRCA-1 and BRCA-2 mutation and risk analysis were not performed routinely because they are not a common practice in our city and require sending patients to another city. Thus, they were not used as criteria for prophylactic mastectomy. In the context of reconstructive surgery, the most important part of the breast organ is the nipple–areola complex due to its distinct sensation and its major roles in aesthetics and function. Reconstruction of the nipple–areola complexes after mastectomy usually is not satisfactory 123 Aesth Plast Surg (2010) 34:71–77 to the patient [20, 21]. Thus, nipple–areola complex– sparing mastectomies performed for peripheral tumors diagnosed at an early stage represent a surgical treatment choice that maximally increases breast aesthetics. Surgical methods developed for repositioning the nipple–areola in ptotic breasts depend on excision of excess skin and reconstruction of the nipple–areola with breastreduction incisions. The incisions performed to decrease the excess skin may cause healing problems at the incision lines and also deteriorate nipple–areola survival. The surgical technique presented in this report to reduce excess skin and facilitate repositioning of the nipple–areola in mid-sized breasts increases nipple–areola survival by protecting the inferior dermal pedicle. The only incision that may jeopardize tissue oxygenation with the proposed technique is the lateral incision performed for mastectomy. This incision allows both sentinel node biopsy and axillary dissection. Wound-healing problems usually are not encountered during subcutaneous mastectomies with no skin reduction. Skin blood perfusion is jeopardized during breast reduction mastectomy. Two mechanisms can be proposed that explain these wound-healing/perfusion issues: long flaps created as a result of skin excision and aggressive surgery that causes very thin skin and jeopardizes the subdermal plexus [16]. With the surgical technique used in this study, full-cut incisions from only the lateral side and deepithelialization instead of skin excision reduces wound-healing problems at suture lines. Use of the inferior dermal barrier flap provides double-layered protection at the suture site and avoids implant exposure even when wound dehiscence occurs. Although the submuscular area is more protective of the prosthesis [22], it is not optimal for larger prostheses. Pressure on the prosthesis can cause low-level breast projection. In addition, preparation of the submuscular area increases the mean time for the surgical procedure. Good aesthetic results can be obtained with subcutaneous placement in the early period. However, the weight of the prosthesis which skin must bear, may cause complaints of early ptosis, rotation of prosthesis, protrusion of the prosthesis, and undulation of the skin surface due to prosthesis pulling. In the study presented here we not encountered with this problem. Especially in young patients for whom prophylactic mastectomy (risk-reducing surgery) is planned, subcutaneous implantation can be performed reliably because the skin is not very thin, as is found with patients who have undergone aggressive surgery due to diagnosed breast cancer. With breast cancer surgery, surgical interventions to protect the nipple–areola are worthy of testing and discussion. In the current study, total necrosis of the nippleareola occurred with an incidence of 7.7%. We consider
  • 7. Aesth Plast Surg (2010) 34:71–77 this an acceptable risk level. Our experience using this technique is that increased breast dimension, increased degree of ptosis, and smoking increase the rate of complications. To determine a reliable zone for this technique, more experience and a large series of cases are needed. Conclusion For patients who plan to undergo subcutaneous mastectomy but have breast cancer or are at high risk for breast cancer (candidates for prophylactic mastectomy), a silicone implant is the easiest choice as a reconstruction material. If these patients have moderate-sized and ptotic breasts, it is necessary to reduce the amount of breast skin and reposition the nipple–areola to achieve better aesthetic results. The reducing pattern and the small and useful mastectomy incisions described with this technique contribute to skin flap and nipple–areola survival. The inferior dermal barrier flap used in this study improves reconstruction reliability by decreasing the breast envelope and forming doublelayered dermal tissue at the incision line. Skin-reducing subcutaneous mastectomy with a dermal barrier flap and simultaneous reconstruction with silicone implants are a good alternative for early-stage breast cancer patients with moderate-sized breasts. References 1. Hinton CP, Doyle PJ, Blamey RW, Davies CJ, Holliday HW, Elston CW (1984) Subcutaneous mastectomy for primary operable breast cancer. Br J Surg 71:469–472 2. Gerber B, Krause A, Reimer T et al (2003) Skin-sparing mastectomy with conservation of the nipple–areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 238:120–127 3. Cunnick GH, Mokbel K (2004) Skin-sparing mastectomy. Am J Surg 188:78–84 4. Nahabedian MY, Tsangaris TN (2006) Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple–areola complex. 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Metcalfe KA, Semple JL, Narod SA (2004) Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study. Plast Reconstr Surg 114:360–366 11. Singletary SE (2001) New issues in surgical management. In: Bonadonna G, Hortobagyi G, Gianni AM (eds) Textbook of breast cancer. Martin Dunitz, Taylor & Francis, Oxford, UK, pp 113–115 12. Jones NB, Wilson J, Kotur L, Stephens J, Farrar WB, Agnese DM (2009) Contralateral prophylactic mastectomy for unilateral breast cancer: an increasing trend at a single institution. Ann Surg Oncol 16:2691–2696 13. Yi M, Meric-Bernstam F, Middleton LP, Arun BK, Bedroisan I, Babiera GV et al (2009) Predictors of contralateral breast cancer in patients with unilateral breast cancer undergoing contralateral prophylactic mastectomy. Cancer 115:962–971 14. Freeman BS (1962) Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg Transplant Bull 30:676–682 15. 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Plast Reconstr Surg 110:457–463 21. Shestak KC, Gabriel A, Landecker A, Peters S, Shestak A, Kim J (2002) Assessment of long-term nipple projection: A comparison of three techniques. Plast Reconstr Surg 110:780–786 22. Gruber RP, Kahn RA, Lash H, Maser MR, Apfelberg DB, Laub DR (1981) Breast reconstruction following mastectomy: a comparison of submuscular and subcutaneous techniques. Plast Reconstr Surg 67:312–317 123