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From the Departments of Surgical Oncology (SES) and Plastic Surgery (GLR), The University of Texas M. D. Anderson Cancer Center, Houston, Texas.
Correspondence: Address correspondence to: S. Eva Singletary, MD, FACS, Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 444, Houston, TX 77030-4095; Fax: 713-792-2225; E-mail: esinglet{at}mdanderson.org
Skin-sparing mastectomy consists of a standard mastectomy that preserves as much of the patient’s skin as is safe in preparation for immediate breast reconstruction. Aside from this preserving the skin, the mastectomy technique is the same as that for a standard total mastectomy with removal of all breast tissue.
In this issue of the Annals of Surgical Oncology, two studies address the oncologic safety of skin-sparing mastectomy. The study by Ho and colleagues1 "Skin Involvement in Invasive Breast Carcinoma: Safety of Skin-Sparing Mastectomy" using step-serial sectioning of the skin of mastectomy specimens demonstrated that the chance of skin involvement in T1 and T2 tumors is very small. The study by Carlson and colleagues2 "Local Recurrence After Skin-Sparing Mastectomy: Tumor Biology or Surgical Conservatism?" provided evidence that local recurrence after mastectomy is a reflection of the aggressiveness of the tumor biology rather than preservation of the skin of the breast. To ensure that skin-sparing mastectomy is oncologically safe, it is important to understand what constitutes a skin-sparing mastectomy, the patient selection criteria, operative technique, and the subsequent risk of tumor recurrence. Care must be taken to explain the priority of adherence of these oncologic principles to each woman considering reconstructive breast surgery, who understandably tends to focus primarily on the favorable cosmetic outcome attainable with this approach.
As with standard mastectomy, obtaining clear margins is paramount in a skin-sparing mastectomy. The oncologic surgeon assists the pathologist in orienting the mastectomy specimen and inks both the anterior and posterior surfaces of the specimen. Any margin close to the tumor or biopsy site should be submitted for frozen section evaluation. For patients with extensive suspicious microcalcifications on mammography, specimen radiography after the mastectomy specimen has been inked and sectioned provides valuable information during the surgery about the radiographic margins.3 If additional skin must be resected because of an inadequate margin, it should be removed without hesitation.
Skin can often be preserved between the biopsy site and the areola either by altering the direction of the incision line to encompass the biopsy scar or by excising the biopsy scar separately. If the cancer diagnosis was obtained by needle biopsy and the lesion is deep within the breast, no skin overlying the area of the tumor needs to be excised. Input from the plastic surgeon is useful during the planning stages, but the final decision on the design of the skin flaps must always rest with the oncologic surgeon with the goal of giving the patient the best chance for a cure.
The thickness of the mastectomy flaps should be the same as those in a standard total mastectomy. The keys to success are to make the flaps uniform in thickness and to avoid thin spots. The biopsy cavity site, along with its scar, should be intact within the mastectomy specimen when the flaps are elevated. The inframammary fold should be left undisturbed and the dissection not extended inferiorly on the rectus abdominis muscle to preserve a more normal contour of the mound of the reconstructed breast. Care taken to not dissect beyond the breast parenchyma and to preserve this fold should not be regarded as leaving breast parenchyma behind.
The skin-sparing mastectomy can be modified to also preserve the nipple-areolar complex. The dogma that the nipple-areola complex must be removed with the mastectomy specimen is based on studies in the 1970s and 1980s that demonstrated occult tumor in the vicinity of the nipple-areola complex. The nipple sampling technique varied among these studies, however. Most often, the technique involved serially sectioning the nipple vertically and the areola horizontally at 5-mm intervals with depths that ranged from 5 to 20 mm. The risk of tumor involvement was higher if the primary tumor was subareolar, larger than 2 cm, or associated with positive axillary lymph nodes. In a retrospective study at The University of Texas M. D. Anderson Cancer Center, Laronga and colleagues4 reported that nipple-areolar complex involvement occurs in only approximately 3% of patients undergoing skin-sparing mastectomies, excluding patients with multicentric or subareolar primary tumors. Women with clinically node-negative disease who have small, solitary tumors on the periphery of the breast have an especially low risk for involvement of the nipple-areola complex and would be good candidates for its preservation. Intraoperative examination of frozen sections of the subareolar margin also helps determine whether the nipple-areola complex can be preserved. The patient should be informed before surgery that the nipple-areola complex must be removed if occult tumor is discovered or if the vascularity of the flap is questionable. If the reconstruction can be successfully performed with an autogenous tissue flap, a small island of skin from the autogenous flap is left visible from the lateral extension of the mastectomy incision to monitor flap viability. Alternatively, a retrospective analysis by Simmons and colleagues5 to determine the frequency of malignant nipple or areolar involvement showed that only 2 of 217 (0.9%) patients had involvement of the areola, compared with 23 patients (10.6%) with occult nipple malignancy.
In actual practice at our institution, however, preservation of the nipple-areola complex is not routinely performed. Special additional considerations for individual patient selection include the size of the breast to be reconstructed and the potential for ischemia of the nipple-areola complex (especially if the areola diameter is large) at the distal aspects of either the upper or lower skin flap. When the oncologic and vascular feasibility of preserving the complex is high, we generally prefer to locate the complex on the lower flap, to minimize the distance for adequate blood supply to the tip of the areola. Preservation of the nipple-areola complex in the common clinical situation of the unilateral mastectomy and reconstruction (either with implant or autogenous tissue) can lead to a displeasing asymmetry of the bilateral nipple-areola positions unless the exact breast position is restored or a symmetry procedure on the opposite breast precisely matches the ultimate nipple position of the reconstructed breast, which inevitably changes over a number of months in postoperative settling. An alternative option to the preservation of the nipple-areola complex that may appeal to some patients involves the removal of the complex with neurotization of the autogenous reconstruction flap to likely provide better sensation to the central portion of the flap with secondary symmetric tattooing of the skin island that replaces the areola.
Fears that skin-sparing mastectomy with immediate reconstruction would increase the likelihood of tumor recurrence have proven unjustified. Rates of local recurrence in patients undergoing immediate reconstruction are no different from those seen in patients undergoing mastectomy alone, as was found in a study of 364 women with invasive stage T1 or T2 breast cancers who had immediate reconstruction after skin-sparing mastectomy.6 In that study, the local recurrence rate was 6.2%, and the median time to recurrence was 25 months.
Radiation treatment can be used for breast cancer recurrences in women who have had an autogenous tissue reconstruction. Rates of complications from radiation treatment given after autogenous reconstruction range from 5% to 16%, with the most common problems being fat necrosis (16%) and fibrosis (11%).7 For women who have had reconstruction with an implant, the complication rate with radiation treatment is high; most develop a capsular contracture, and capsulotomy has been required in up to 43% of patients.8 As a result, our current approach involves the diligent education of women with early breast cancer about reconstruction with particular attention paid to the possible cosmetically compromising complications related to radiotherapy for those patients who will most likely need postoperative adjuvant radiotherapy such as women with four or more positive axillary lymph nodes or stage III disease.9 Many patients may consequently elect to delay reconstruction or seek agreement from their plastic surgeon before electing immediate reconstruction. Another option for women with early breast cancer who have a higher likelihood of needing radiotherapy involves placing a tissue expander in the skin-sparing mastectomy envelope under the pectoralis major muscle and awaiting the final pathology results and then completing the "delayed immediate" reconstruction if no radiation is needed or deflating the expander for radiation treatments as clinically necessary.
Skin-sparing mastectomy with immediate breast reconstruction for women with early breast cancer can produce excellent cosmetic results and has been shown to be as safe as delayed reconstruction. The patient should consult with the plastic surgeon before undergoing mastectomy to gather information and determine whether immediate breast reconstruction is the right choice for her. If the patient is unsure about having an immediate or any breast reconstruction, she can defer the decision and return later for delayed reconstruction or choose to have no reconstruction at all.
Received for publication January 7, 2003. Accepted for publication January 14, 2003.
REFERENCES
This article has been cited by other articles:
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  M. Gutman Breast Conservation for T1-2 Breast Carcinomas Ann. Surg. Oncol., October 1, 2003; 10(8): 994 - 995. [Full Text] [PDF]
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