The document discusses the history and techniques of breast incisions for cancer surgery and reconstruction. It outlines how the transverse elliptical incision became standard but often led to unnatural breast shapes. The Wise pattern introduced in 1956 uses skin tailoring within a keyhole pattern to better preserve the breast's natural appearance and shape. Today, multidisciplinary teams plan oncologically justified incisions tailored to each patient's breast within the Wise pattern principles for optimal cosmetic and medical outcomes.

1. BREAST INCISIONS a history, basic science and technique of The New Standard of Care Joel A. Aronowitz, MD Division of Plastic Surgery Cedars Sinai Medical Center Los Angeles, CA Conflict of Interest Disclosure: Nothing to disclose

3. General anesthesia opens modern era in surgery, Halstead attempts cure with radical surgery

4. “ Breast cancer wars” Crile vs Halstead the modified radical mastectomy emerges Transverse incision with elliptical skin excision is established

5. Open Biopsy and Lumpectomy Incisions Concentric circles & Langer’s Lines

7. before after Oncologic breast incisions and reconstruction, c.1990’s

8. before After bilateral mastectomy TRAM reconstruction Courtesy J. Anderson, COH Nat’l Med.Ctr The New Standard of Care 1. Low threshold use of needle biopsy 2. Incisions planned with 1st principles 3. Skin resection justified oncologically 4. Multidisciplinary approach

10. LaPlace predicts breast shape Breast diameter is > in lower pole therefore the skin below the nipple is under greater tension and stretches the most. Nipple decent with the breast.

11. Chest shape may influence breast shape; pectus deformity

14. Typical Skin Envelope after Transverse Mastectomy

16. How Transverse Incision Results in Typical Superior Pole Fullness

18. Incision Placement periareolar or IM crease incision

19. Operative Technique Cancer bearing breast tissue removed, not skin. Blunt retractors, no sharp rakes on skin flaps.

20. A Segway slide…

22. Keyhole vs Transverse

26. Tailoring redundant skin in male vs female breast

30. Lateral flap resection

35. Mastectomy after breast reduction

36. Wise pattern after mastectomy