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Skin-sparing and subcutaneous mastectomy (nipple-sparing mastectomy) with immediate reconstruction

Over the years, the surgical management of breast cancer has significantly evolved. There is more emphasis on obtaining excellent aesthetic results without compromising on the oncological safety of the operation. Oncoplastic techniques mean that women are being offered more complex procedures in order to safely remove the cancer but allow a good cosmetic outcome.

A skin-sparing mastectomy (SSM) removes the breast, nipple, and areolar complex and a subcutaneous or nipple-sparing mastectomy will preserve the nipple and areolar complex.

Preservation of the inframammary fold, the skin overlying the breast, and potentially the nipple and areolar complex greatly enhances the aesthetic results of immediate breast reconstruction.

The procedure can be performed as a unilateral procedure or bilateral (removal of both breasts with an immediate bilateral breast reconstruction).

A variety of incisions may be made that are relatively inconspicuous and are easily hidden and closed.

Studies comparing the local recurrence of breast cancer associated with skin-sparing mastectomy and conventional total mastectomy have found no significant differences. The data have also shown that the selective use of nipple-sparing mastectomy in the treatment of early breast cancer has a low index of recurrence in the nipple and areolar complex (Chong et al. 2008).

Some patients may require a contralateral (opposite side) mastopexy or reduction to improve symmetry.

Patients may elect to undergo an immediate breast reconstruction with a tissue expander or may choose to use autologous tissue (tissue from their body) to reconstruct the breast (see prophylactic mastectomy with immediate reconstruction).

If a tissue expander is used the expander may be inflated immediately with saline depending on the quality of the soft tissue/skin coverage over the expander, further gradual expansion will usually begin 2-3 weeks after surgery but depends on the skin flap viability and wound healing. The expander is gradually expanded using magnetic port locators, with saline every 2-3 weeks until the desired volume/breast size is reached. The expander is usually slightly overexpanded to gain more tissue for creating a more natural ptosis. New tissue expanders which will allow patients to self-inflate with air will soon be available. Expansion is usually maintained over a 2- to 6-month period, although some women will leave tissue expanders in for a prolonged time. After removal of the tissue expander, the patient may decide to undergo breast reconstruction with insertion of an implant or at that stage may decide to use autologous tissue. This is usually with the use of a free-flap.

Patients that are undergoing radiotherapy will usually have the radiotherapy delivered while the expander is in situ and will proceed to the permanent reconstructive procedure at least 6 months after radiotherapy.

The advantages of implants include the absence of donor site morbidity and the simplicity of the breast reconstruction. However, some patients do not like the unnatural feel or look of the breast and there is always the possibility that further procedures are required, in particular implant exchanges due to capsular contracture. Some patients may perceive that the implant placed under the muscle is a foreign body and in patients receiving post operative radiotherapy there is increased risk of capsular contracture after chest wall irradiation.

The use of autologous tissue improves the natural look of the reconstructed breast and in most cases provides a long-term natural result. The ideal tissue for breast reconstruction is fat. Thus, a good source of this fat is from the patient’s lower abdomen. The fat in this area is typically soft and easy to shape. For most patients, an added bonus of an abdominal donor site is improved abdominal contour following the removal of the flap as in an abdominoplasty (tummy tuck).

Breast reconstruction using autologous tissue from the lower abdomen was first described by Holmstrom in terms of a free flap in 1979. The technique has been improved over the years and the latest evolution of soft tissue flap is currently the DIEP flap (deep inferior epigastric perforator flap). The use of this flap minimises the donor site morbidity (reduces the risk of bulges, hernias, and weakness of the abdominal wall) and optimises flap durability of transferred tissue. The deep inferior epigastric perforator flap was developed by Koshima and Soeda in 1989. The use of this flap is associated with a less postoperative pain and a shortened recovery time compared to TRAM flap (transverse rectus abdominus myocutaneous flap). Abdominal wall strength in patients with breast reconstruction with a DIEP flap is maintained.

The patient’s general health and oncological situation needs to be carefully examined before the procedure. Not all patients will be suitable for autologous tissue reconstruction. Patients who have a previous history of abdominoplasty; patients who have major medical comorbidities including cardiovascular, autoimmune, or chronic lung disease; patients who are smokers; and patients who have previously had liposuction of the lower abdomen may be contraindicated for the surgery.

If the nipple and areolar complex is sacrificed at the time of surgery, there are a variety of reconstructive options to create a new nipple and areolar complex. These include local flap, free flap (skin taken from another area in the body) to recreate the nipple and areolar complex, and nipple tattooing. The nipple reconstruction is usually done at a later date. If a unilateral mastectomy is undertaken, there is always the possibility of the nipple from the contralateral breast being shared with the opposite breast (a composite graft).