BREAST

Skin-Reducing Mastectomy
Maurizio B. Nava, M.D.
Background: The authors propose a combined flap technique to reconstruct
Umberto Cortinovis, M.D. large and medium-sized ptotic breasts in a single-stage operation by use of
Joseph Ottolenghi, M.D. anatomical permanent implants.
Egidio Riggio, M.D. Methods: The authors enrolled 28 patients fulfilling criteria for skin-sparing
Angela Pennati, M.D. mastectomy and presenting with ptotic breasts whose areola-to-inframammary
Giuseppe Catanuto, M.D. fold distance was more than 8 cm. All reconstructions were performed as a
Marco Greco, M.D. single-stage procedure. After preoperative planning, a large area in the lower
Guidubaldo Querci della half of the breast was deepithelialized according to the conventional Wise
Rovere, M.D. pattern. Mastectomy was then carried out. To perform reconstructions, the
Milan, Italy; and London, United inferomedial fibers of the pectoralis major muscle were dissected and sutured
Kingdom to the superior border of the inferior dermal flap. An anatomical implant was
then inserted into the pouch, which was closed laterally with the previously
harvested serratus anterior fascia. Skin flaps were finally closed down to the
inframammary fold.
Results: The authors performed 30 procedures on 28 patients. The medium
size anatomical implants was 433 cc. Twelve women achieved symmetrization
in a single stage ending in a symmetric inverted-T scar. The overall com-
plication rate was 20 percent, with four cases (13 percent) complicated by
severe, extensive necrosis of the skin flaps requiring implant removal.
Conclusions: Breast cancer treatment must nowadays optimize cosmetic
results. This can be accomplished in selected cases by means of a single-stage
operation that the authors call “skin-reducing mastectomy.” The final scars
imitate those of cosmetic surgery. Careful patient selection and improvement
in the learning curve may reduce the complication rate. (Plast. Reconstr.
Surg. 118: 603, 2006.)

S
kin-sparing mastectomy was introduced a conspicuous reduction of the skin envelope
into clinical practice several years ago and and a contralateral mastopexy or reduction.
is now considered an oncologically safe sur- Reconstruction surgery in this subset of mastec-
gical procedure.1–5 Saving the skin envelope and tomies can be performed by means of totally sub-
inframammary fold improves the reconstructive muscular expanders or permanent prostheses
outcome of a conventional radical modified or rather than autologous flaps. Final scarring is sim-
simple mastectomy and avoids unpleasant scar- ilar to that from cosmetic surgery (inverted T).
ring. This technique has two main limitations. First,
Carlson and colleagues6 classified skin-sparing the two long superior flaps that close down to the
mastectomy into four categories based on type of inframammary fold may become ischemic, be-
incision used and amount of skin removed. cause of their length and thinness. This could re-
Types I, II, and III of this classification involve sult in healing complications of the inverted-T scar,
mainly small breasts and take into consideration such as superficial epidermolysis, wound dehis-
the position of a previous biopsy scar. In all of cence, and implant exposure.7 Second, a perma-
these cases, mastectomy is carried out through a nent prosthesis in the lower pole of the recon-
periareolar approach. Type IV skin-sparing mas- structed breast lacks projection, resulting in
tectomy involves large ptotic breasts that require excessive upper pole fullness. This inconvenience
can be overcome in part by means of a two-step
From the Plastic and Reconstructive Surgery and Breast operation initially using tissue expansion.
Units, Istituto Nazionale Tumori, and the Breast Unit, In this study, we describe an alternative tech-
Royal Marsden Hospital, National Health Service.
Received for publication March 26, 2005; accepted May 26, nique to minimize complications and poor cos-
2005. metic results in a single-step operation using ana-
Copyright ©2006 by the American Society of Plastic Surgeons tomical silicone gel implants and a dermal-muscle
DOI: 10.1097/01.prs.0000233024.08392.14 flap pocket.

www.PRSJournal.com 603
 Plastic and Reconstructive Surgery • September 1, 2006

PATIENTS AND METHODS

We enrolled 28 patients on behalf of Istituto
Nazionale Tumori, in Milan, Italy, from Septem-
ber of 2001 to October of 2004. All patients ful-
filled the oncological criteria for skin-sparing mas-
tectomy.
We submitted all patients to reconstructive cri-
teria and included all women who presented with
sagging breasts and an areola-to-inframammary
fold distance of more than 8 cm and a nipple-to-
areola distance of more than 25 cm in the trial for
this technique.
Operations were performed by a team made
up of a surgical oncologist and a plastic surgeon.
All reconstructions were performed as a single-
stage procedure. We used McGhan style 410/510
highly cohesive silicone gel anatomical perma- Fig. 1. Preoperative markings for skin-reducing mastectomy on
nent implants (Inamed, a Division of Allergan the left breast and mastopexy on the right breast.
Inc., Irvine, Calif.), with full and extra-full projec-
tion. Cosmetic and reconstructive results were as-
sessed by plastic surgeons comparing preoperative thelialization of a large lower area of skin between
and postoperative photographs. the inframammary line and the medial and lateral
All data were collected retrospectively from extensions of the reduction pattern.
the clinical medical data records. Before the mastectomy is started, the lower
flap is sculpted down to the inframammary fold,
whose anatomy we always identify to allow care-
Surgical Technique
ful preservation. The gland has to be removed
The Preoperative Project with accurate sparing of the superior flap’s sub-
As with all surgical procedures we perform dermal vascularization. We always tend to dissect
for breast reconstruction or reshaping after following Cooper’s ligaments plane, to mini-
wide local excision, our strategy begins with a mize ischemia without compromising oncologic
careful preoperative assessment. With the pa- safety and complete removal of breast tissue.
tient standing in front of us, we first mark the This access usually allows for easy axillary dis-
position of the new nipple along the midcla- section or sentinel node identification and biopsy.
vicular line at a distance between 19 and 23 cm. After the oncologic procedures are completed, we
The marking then follows the steps used for a start the reconstruction by incising along the lat-
normal breast reduction or mastopexy using a eral border of pectoralis major. The inferior and
conventional Wise pattern; however, on the mas- lower-medial insertions of this muscle are divided
tectomy side, we erase the semicircular drawing and sutured to the superior border of the dermal
representing the position of the new nipple- flap (Fig. 2, above, right). A large pouch is then
areola complex and we prolong the two vertical created to accommodate an anatomically shaped
limbs up to the new nipple position. The length permanent prosthesis. The pouch is then closed
of the two limbs on this side depends on the laterally with the previously raised serratus muscle
degree of reduction we want to achieve and is (Fig. 2, below, left). Before the pouch is closed, a
usually between 5 and 7 cm, plus the 2 cm radius suction drain is placed inside it. Once the viability
of the nipple-areola complex. The distal ends of of the cutaneous flaps has been carefully assessed,
the two limbs are then extended medially and the skin is sutured by approximating the distal end
laterally with patient lying in the supine posi- of the two vertical limbs to the inframammary line.
tion, so as to intercept the previously marked The nipple is usually reconstructed in a sec-
inframammary fold (Figs. 1 and 2, above, left). ond step with the patient under local anesthesia.
Surgical Procedure In selected cases, nipple autotransplantation can
Skin is incised full thickness along the vertical be performed, even if it remains unclear whether
limbs of the reduction pattern, including only the the superior flap can provide adequate vascular-
epidermis (partial thickness) after the inframam- ization to the skin graft. In a few cases, we recon-
mary line. A dermal flap is then created by deepi- structed the nipple intraoperatively with local skin

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Volume 118, Number 3 • Skin-Reducing Mastectomy

Fig. 2. (Above, left) Preoperative markings for right skin-reducing mastectomy. (Above, right) The lower border of the pectoralis major
muscle is sutured to the inferior dermal flap. (Below, left) The serratus fascia is raised to close the pouch laterally. (Below, right) Post-
operative result.

flaps (Fig. 2, below, right). There is still concern eral breast cancer (T1N1 on one side and T2N1
regarding the oncologic safety of nipple preser- contralaterally).
vation in cancer patients.7 In this case, we normally A single patient was at high risk because of
perform frozen section analysis of retroareolar gene mutations and had undergone a bilateral
breast ducts. prophylactic mastectomy, and two patients (7.14
percent), after breast cancer on one side, decided
to undergo contralateral prophylactic mastectomy
RESULTS (Fig. 3). We used this technique for a case of
We performed 30 procedures in 28 patients. benign extensive disease (chronic breast abscess).
The median patient age was 47 years (range, 33 to In seven patients (25 percent), we performed
67 years). There was a median follow-up of 13.6 axillary dissection; six dissections were performed
months. Six patients (21.4 percent) were smokers. through a mastectomy incision and one dissection
We subdivided patients into groups according required a separated incision in the axilla. We
to the stage of disease: five patients (17.9 percent) identified and excised 15 sentinel nodes (50 per-
had Tis, one patient (3.6 percent) had Tis(Paget), 13 cent). In no case did we need a new lateral inci-
patients (46.4 percent) had T1N0, one patient had sion.
T1N1 with associated extensive ductal carcinoma One patient had bilateral mastectomy for bi-
in situ not suitable for conservation, one patient lateral invasive breast cancer. For reconstruction,
had T2N0, and two patients (7.14 percent) had style 410/510 anatomically shaped, highly cohe-
T2N1 disease. One patient presented with bilat- sive silicone gel implants were used; the medium

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 Plastic and Reconstructive Surgery • September 1, 2006

cases. None of the uncomplicated cases reported

capsular contracture (Baker I, 78 percent; Baker
II, 28 percent) All patients who had invasive can-
cer received adjuvant chemotherapy. No patient
received postoperative radiation therapy to the
chest wall, internal mammary chain, or supracla-
vicular fossa.

DISCUSSION
In 1991, Toth and Lappert introduced,7 for
the first time, the idea of preoperative plastic sur-
gery planning and skin-saving techniques in pa-
tients undergoing simple or radical modified mas-
tectomies. The oncological safety of this
procedure has recently been demonstrated in sev-
eral studies, and skin-sparing mastectomy is the
technique of choice in some patients.1–5 Small-
breasted women can be reconstructed using per-
manent prostheses or temporary expanders. In
these cases, the breast can be easily removed
through a periareolar approach.
Large or medium-sized breasts are usually
ptotic and require a variable degree of skin re-
duction and a contralateral symmetrization for an
acceptable cosmetic and reconstructive outcome.
This is normally accomplished by removing a
larger island of skin, including the nipple-areola
complex, thereby creating the usual submuscular
pocket filled with a temporary expander. A second
Fig. 3. Prophylactic skin-reducing mastectomy was performed operation is then necessary to reach the final re-
on the left breast due to gene mutation. The patient underwent constructive result, and it is not really possible to
a two-stage reconstruction on the right breast (above, preoper- carefully predict the result from the initial mas-
ative view; below, 16-month postoperative view). tectomy. Scarring in this case is particularly un-
pleasant and asymmetric when contralateral
breast symmetrization is carried out.
size implant was 433 cc, the largest implant was 620 Mastectomies in large breasts using the plastic
cc, and the smallest was 195 cc. surgery techniques described by Toth and
We performed 12 contralateral symmetriza- Lappert7 could, in theory, achieve a rewarding
tion procedures (40 percent) in one stage. In outcome. However, several difficulties need to be
seven cases, we performed an inferior pedicle overcome.
breast reduction, and in five cases we performed One limitation is related to the relative lack of
a mastopexy. space in the inferior and medial aspects of the
Three patients had one-stage nipple recon- submuscular pocket. It is possible to release the
struction in the operating room, one with by local inferior fibers of the pectoralis major, but in this
skin flaps and two with nipple-areola skin grafts case, a subcutaneous implant could easily become
(one bilaterally). Second-stage nipple reconstruc- exposed, especially when it is put underneath the
tion was performed in six cases 6 months after long and possibly ischemic superior mastectomy
implant allocation. flap. This length, as Toth and Lappert7 themselves
Six patients developed superficial epidermol- describe, is critical in determining severe compli-
ysis initially treated conservatively by regular dress- cations not rare if the oncologist during dissection
ing. Four patients required implant removal be- needs to leave very thin poorly vascularized flaps.
cause of exposure after necrosis of the superior Many authors have tried to overcome necro-
flaps. Three of these patients were smokers. After sis and poor results using a modified Wise
complete healing of the wound, a new reconstruc- pattern8 rather than a subcutaneous pouch.9 A
tion was carried out with tissue expansion in all the muscle-skin combined pocket for permanent

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implant allocation was described for prophylac- tions of type IV mastectomy to all patients requir-
tic and cosmetic purposes by Bostwick in the ing a cosmetic procedure with an inverted-T scar
early 1990s.10 At that time, there was no infor- on the contralateral breast (Table 1). An 8-cm
mation on the possibility of saving skin during distance between the areola and inframammary
oncologic procedures. In the technique, a fold has been considered the minimum length
pouch made up of pectoralis major and serratus needed to create a viable dermal flap and a pocket
anterior is closed anteriorly by the lower dermal large enough to accommodate a prosthesis. In all
flap deepithelialized before starting mastec- other cases, skin-sparing mastectomy can be better
tomy. This allows room for the lower aspects of carried out using a periareolar approach. Symme-
the reconstruction and protects the implant by trization could be easily planned for the same
means of a two-layer cover. The nipple-areola operation. However, we gave all of our patients the
complex is subsequently grafted in the new po- choice of having surgery or not on the healthy
sition at the top of the inverted T. breast and therefore the chance of a second op-
Hammond et al.11 introduced Bostwick’s idea eration whenever they felt it was appropriate. Con-
in breast cancer treatment. They modified the tralateral immediate reduction/mastopexy was
original technique using temporary expanders in performed in 11 patients. The inferior pedicle
the large majority of the cases presented, mandat- technique seems to be the most suitable when a
ing a second operation for permanent implant reduction is needed, whereas for mastopexy we
insertion. We decided to follow Bostwick’s original prefer a superior pedicle technique, folding the
technique in our study, and that allowed us to deepithelialized inferior pole of the breast into
obtain a cosmetically satisfying reconstruction in a the retroareolar space as an “auto-prosthesis.”
single-step operation. The nipple-areola complex was usually recon-
Use of an anatomical prosthesis when allocated structed in local anesthesia as a day case proce-
under a wide dermal-muscle flap pocket gives an dure. We preserved and subsequently grafted the
immediate final aspect to the reconstructed breast. nipple-areola complex in only two patients who
Careful saving of the inframammary fold allowed us had special concerns regarding cosmesis. Both
to obtain an immediate natural ptosis.12 In our in- were cancer patients, so we performed a frozen
stitution, mastectomies are conventionally accom- section before grafting. The results showed no
plished by preserving the serratus and pectoralis cancerous tissue in the retroareolar ducts. One
major fascia. If a patient is scheduled to undergo a patient had a bilateral mastectomy, but because of
skin-sparing mastectomy, she should not have chest a heavy smoking addiction, one graft totally failed
wall infiltration diagnosed preoperatively. However, and the other survived only partially. The second
if intraoperatively, for oncological safety, wider ex- grafted patient had no complications.
cision of fascia is required, we suggest either leaving In many series describing inverted-T mastec-
the pouch open in the lateral aspect or closing it tomies, a high complication rate is reported (up to
with serratus fibers carefully elevated together with 27 percent), especially at the T junction6,9,11,14 (Ta-
the pectoralis major. An alternative option could be ble 2). Toth and Lappert, in the earliest article
offered by human acellular tissue matrix regarding skin-sparing mastectomies, reported
implantation.13 This is a rather new skill in breast skin problems in four cases of inverted-T proce-
reconstruction, and we are waiting for further vali- dures reconstructed with transverse rectus abdo-
dation from clinical studies before introducing it minis musculocutaneous flaps.7 Carlson et al., in
into current clinical practice. their 1997 series, indicated a 27 percent compli-
By using the combined pouch, we had the cation rate for type IV mastectomy.6 All patients
chance to allocate large mammary implants (me- were presumably treated with autologous flap re-
dium volume, 433 cc). The large superior access has construction. Further observation from Carlson
given us the possibility of identifying sentinel lymph on an enlarged population confirmed the previ-
nodes in all cases and avoiding a second scar in the ously reported percentage (26.5 percent).14 A
armpit. Even axillary dissection in the large majority higher failed reconstruction rate is to be expected
of cases (85 percent) can be performed through this in an implant-based technique. Hammond et al.11
access. Regardless, it is advisable to avoid strong re- and Hudson and Skoll9 reconstructed the breast
traction to prevent flap problems while exposing the mound after inverted-T procedures by using either
anatomical structures. temporary expanders in a two-stage operation or per-
The aesthetic purpose of this operation is op- manent subcutaneous prostheses. Hammond et al. de-
timized by contralateral symmetrization (Fig. 4). scribed two out of 19 reconstructions with complica-
In view of this, we decided to extend the indica- tions, with one case progressing to implant extrusion.

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 Plastic and Reconstructive Surgery • September 1, 2006

Fig. 4. Oncologic and cosmetic treatment performed during the same operation. (Above) Preoperative views. (Below) Postoperative
views.

Table 1. Skin-Reducing Mastectomy: Oncologic and Reconstructive Criteria

Oncologic Criteria Reconstructive Criteria
• Invasive carcinoma unsuitable for breast conservation • Medium-sized or large ptotic breasts
• Multicentric carcinoma with no evidence of skin • Nipple-sternal notch distance ⬎25 cm
involvement • Areola-inframammary fold distance ⬎8 cm
• Paget’s disease of the nipple associated with either in • To be avoided in smokers and patients with microvascular
situ or invasive carcinoma in peripheral location problems (previous radiotherapy, diabetes)
• Extensive ductal carcinoma in situ
• Prophylactic mastectomy
• Post neoadjuvant chemotherapy in which conservation
is still not indicated

Hudson and Skoll, allocating implants subcutaneously, nor wound dehiscence. One-third resolved with con-
reported extrusion in three cases. They provide a thor- servative treatment, while the other two-thirds pro-
ough description of the complicated cases, and all were gressed to necrosis and implant exposure. As expected,
related to compromised peripheral microcirculation catecholamine released due to the effects of nicotine
in heavy smokers or diabetics. With our technique, we damaged the vascularity of thin and long skin flaps.15
observed a 13 percent rate of severe complications Carlson et al. correlated tobacco smoking with a sig-
requiring implant removal and an overall complication nificantly higher rate of necrosis in a subset of smokers
rate of 20 percent (skin problems). Complications in who underwent skin-sparing mastectomy (49 percent
our study began with superficial epidermolysis or mi- versus 19 percent in the nonsmoking group, p ⬍

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Table 2. Inverted-T Mastectomy Reconstructive Technique and Complication Rate

Authors (ref.) No. of Type of Total No. Minor Implant
Cases Reconstruction of Complications Complications Extrusion
Toth and Lappert, 19917 –* TRAM flaps 4* 4* (superficial –
epidermolysis)
Carlson et al., 19976 44 Not reported, presumably TRAM flaps 12/44 (27%) – –
Hammond et al., 200211 12 Two-stage implant reconstruction 2/12 (16.6%) 1/12 (8.3%) 1/12 (8.3%)
Hudson and Skoll, 20029 19 Single-stage implant reconstruction 3/19 (15.7%) Not reported 3/19 (15.7%)
Carlson, 200414 68 Not reported, presumably TRAM flaps 18 (26.5%) – –
*Number of Wise pattern mastectomies was not specified. All complicated cases were inverted-T mastectomies.

0.001).6 In our series, 75 percent of the implants re- pearance of the new breast. Final results were
moved were from patients who smoked more than 20 judged by plastic surgeons and patients as ex-
cigarettes per day. Some authors suggested intraoper- tremely satisfying, especially with regard to the
ative assessment of skin viability with fluorescein to optimal degree of ptosis and appropriate distri-
prevent ischemia.11 We, in accordance with Carlson et bution of volume between the superior and infe-
al., did not find this device to be helpful, relying only rior and medial and lateral aspects of the breast.
on clinical observation of skin flap color and red bleed- All of our patients were rated as having Baker
ing from the edges.14 grade I or II contracture (median follow-up, 13.6
In view of our report, we advise surgeons to months). In our opinion, complete release of the
avoid using the described technique in heavy inferomedial pectoralis major fibers and the in-
smokers and whenever microvascular disease ferior dual dermal-adipose plane allowed for a
(e.g., diabetes, postradiation therapy, and so on) very soft and natural reconstruction.
is present. In our opinion, the complication rate
can be lowered by accurate patient selection and
improving the learning curve of the technique. CONCLUSIONS
Although the latissimus dorsi flap plays a ma- Oncologic procedures in breast cancer nowa-
jor role in repairing failed reconstructions caused days must consider accurate preoperative assess-
by extensive skin necrosis, we never used it as a
ment to optimize cosmetic results. Large or me-
salvage flap. In all our complicated cases, skin flaps
dium-sized breast cosmesis often requires a certain
were still large enough to allow expander alloca-
tion and a conventional two-stage procedure. degree of skin envelope reduction. This can be
Whenever it was not strictly required, we tended to accomplished in eligible cases by means of a sin-
preserve large myocutaneous flaps to reduce bio- gle-step operation that we call a “skin-reducing
mechanical sequelae16 and to keep them available mastectomy.” On the basis of this study, we are
for further reconstructions. going to offer all of our patients who meet appro-
A possible option to reduce risks and optimize priate oncologic and reconstructive criteria this
cosmetic results could consist of using a vertical kind of treatment.
approach to mastectomy, with a limited skin take- Our goal will be to assess accurately in a large
out followed by a periareolar and vertical skin series the complication rate and cosmetic results.
closure.14 This is an interesting access to be even- We believe that once the safety of this technique
tually endorsed in preoperative plastic surgery has been successfully achieved and demonstrated,
planning for mastectomy. In our opinion, how- it can be adopted extensively. The majority of
ever, it does not seem to be appropriate in very women who need a mastectomy usually present
large and ptotic glands (Fig. 4). We would con- with an excessive skin envelope. All of them can be
sider it for medium-sized ptotic breasts and even offered a skin-reducing mastectomy, and by means
to produce symmetrical scars. The decision in of a single operation, we might be able to mini-
these cases always has to be left to the patient, with mize unpleasant scarring and offer a favorable
the surgeon possibly offering the patient the cosmetic and psychological outcome.
chance to undergo a two-stage procedure with
contralateral augmentation. This strategy, accord- Maurizio B. Nava, M.D.
Plastic and Reconstructive Surgery Unit
ing to our experience, produces extremely satis- Istituto Nazionale Tumori
fying cosmetic results. Via G. Venezian 1
Capsular contracture is one of the main issues 20133, Milan, Italy
in implant reconstructions affecting the final ap- [email protected]

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 Plastic and Reconstructive Surgery • September 1, 2006

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