Chapter 156: Skin Reduction Mastectomy with Reconstruction

BACKGROUND

Skin-sparing mastectomy (SSM) has emerged as an oncologically safe approach to early-stage breast cancer and prophylactic mastectomies.^1,2 This technique improves aesthetic outcomes by preserving the maximum amount of native anatomy including the inframammary fold, which improves the shape and position of the breast mound. The maximal amount of uninvolved skin is preserved, reducing or removing the need for a reconstructive skin paddle. The aesthetic results using this native envelope cannot be matched by any reconstructive technique.

With the advent of SSM, reconstructive efforts began to focus on optimizing incision placement and managing the residual skin envelope. Common approaches for SSM include the elliptical, periareolar, and periareolar with lateral extension skin patterns.^3,4 These approaches do not address the specific reconstructive needs in a large, ptotic breast.

Skin-reduction mastectomy is the application of SSM technique in the setting of macromastia. The large breast poses a unique challenge to reconstruction.⁴ The residual envelope is ill-suited for implant or autologous reconstruction, and the accompanying ptosis does not result in an aesthetically pleasing breast. Mastectomy techniques which employ standard breast reduction patterns have been created to address this problem. The pattern is designed to correct the ptosis and shape the skin envelope. For unilateral reconstructions, this allows for improved symmetry with a contralateral reduction pattern. In bilateral reconstruction, the pattern improves the final shape of the breasts. When employed with nipple-sparing mastectomy, the pattern incorporates elevation of the nipple-areolar complex (NAC) into the design.

Toth and Lappert¹ appreciated the benefit of preoperative reconstruction planning in SSM. He described skin reductions which excised full-thickness skin in the standard Wise pattern. Bostwick⁵ modified this technique to utilize the preserved skin by de-epithelializing the reduction pattern. The remaining adipofascial flap was secured to the pectoralis muscle to provide an additional layer of tissue under the mastectomy skin. Hammond et al⁶ further modified this technique to optimize the aesthetic benefits of complete implant coverage without the constriction of a lower pole muscle flap (Fig. 156-1A, B).

The Wise-pattern reductions involve closure in the standard inverted-T pattern, which has an increased risk of marginal necrosis at the "T" point. The de-epithelialized lower flap provides additional deep coverage in the event of marginal necrosis. Vertical reduction patterns have also been described and have the benefit of avoiding the "T" point, but they lack incorporation of the adipofascial flap.^3,7,8

Skin-reduction mastectomy patterns need ...