Overview
Definition:
The Wise pattern mastectomy, also known as the inframammary fold pattern or Wise pattern reduction pattern mastectomy, is a surgical technique used for breast cancer treatment and breast reduction
It involves a curvilinear incision in the inframammary fold (IMF) that extends upwards towards the nipple-areola complex (NAC), creating a "keyhole" or "anchor" shaped scar
This approach allows for extensive skin and glandular resection while facilitating optimal aesthetic outcomes and oncologic safety.
Epidemiology:
While not a standalone disease entity, Wise pattern mastectomy is employed in a significant proportion of breast cancer surgeries requiring mastectomy, particularly in cases of macromastia or ptosis where traditional breast-sparing techniques are insufficient or undesirable
Its use in breast reduction surgeries is also widespread, addressing concerns of gigantomastia and related symptoms.
Clinical Significance:
This technique is crucial for surgeons managing breast cancer in patients with large or pendulous breasts, enabling adequate tumor resection with improved cosmetic results compared to standard transverse or superior pedicle techniques
It is also vital for alleviating symptoms associated with macromastia, such as back and neck pain, and improving quality of life
Understanding this pattern is essential for DNB and NEET SS candidates preparing for breast surgery viva voce and practical examinations.
Indications
Oncologic Indications:
Mastectomy for breast cancer in patients with macromastia or significant breast ptosis
Tumors located centrally or in the inferior quadrants that necessitate significant glandular tissue removal
Patients desiring breast conservation but having macromastia that would lead to poor aesthetic outcome with lumpectomy alone and requiring a mastectomy with immediate or delayed reconstruction.
Reconstructive Indications:
Reduction mammoplasty in cases of gigantomastia or symptomatic macromastia where a significant reduction in breast volume is desired
Correction of breast asymmetry with significant ptosis where a standard reduction is not sufficient.
Contraindications:
Active local infection
Uncontrolled comorbidities that preclude extensive surgery
Severe coagulopathy
Neoadjuvant chemotherapy in certain protocols where definitive surgery timing is critical
Patients unwilling or unable to comply with postoperative care.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination, including assessment of breast size, ptosis grade, presence of comorbidities, and patient expectations
Detailed discussion of surgical risks, benefits, alternatives, and expected outcomes, including scar appearance
Preoperative photographs are essential for documentation and planning.
Imaging And Biopsies:
Mammography, ultrasound, and MRI as indicated for tumor staging
Biopsy confirmation of malignancy
Sentinel lymph node biopsy planning if indicated.
Surgical Planning:
Marking the planned incision lines, NAC position, and extent of skin and glandular resection
Consideration for contralateral symmetrization mastopexy or reduction in select cases
Antibiotic prophylaxis initiated preoperatively.
Procedure Steps
Anesthesia And Positioning:
General anesthesia is typically used
The patient is positioned in a supine position with arms abducted
Careful draping to allow access to the entire breast and axilla.
Incision And Dissection:
The Wise pattern incision is meticulously marked, extending along the IMF and superiorly towards the NAC
Dissection is carried down to the pectoralis fascia
Subcutaneous flaps are elevated, preserving adequate thickness to ensure vascularity and minimize dehiscence
The NAC is typically incorporated within the resected specimen or preserved based on tumor proximity and technique.
Glandular Excision And Hemostasis:
The breast parenchyma is excised en bloc with the skin, ensuring adequate margins for oncologic safety
Hemostasis is meticulously achieved using electrocautery and ligation of vessels
Lymph node dissection or sentinel lymph node biopsy is performed as per oncologic indications.
Breast Reshaping And Closure:
The remaining glandular tissue is reshaped to create a more aesthetically pleasing breast mound
The superior flap is advanced downwards to meet the inferior flap, and the skin is closed in multiple layers, often with buried sutures and a final skin closure
Drains are typically placed to manage seroma
The NAC is reconstructed or repositioned if preserved
Immediate reconstruction with implants or autologous tissue may be performed concurrently.
Scar Management:
The resulting scar is a curvilinear incision along the IMF and a vertical limb extending superiorly
Scar management strategies are discussed with the patient postoperatively.
Postoperative Care
Pain Management:
Adequate analgesia is provided, often with a combination of oral and intravenous medications
Patient-controlled analgesia (PCA) may be used in the immediate postoperative period.
Drain Management:
Surgical drains are typically in place and are removed when the output is less than 20-30 ml per 24 hours
Monitoring for drain output is crucial.
Wound Care:
Dressing changes as per protocol
Monitoring for signs of infection, dehiscence, or hematoma
Application of surgical bras or compressive dressings to support the breast mound and reduce edema.
Activity Restrictions:
Patients are advised to avoid strenuous activity, heavy lifting, and sleeping on their stomach for several weeks
Gradual return to normal activities is encouraged as tolerated
Arm movement may be restricted initially to protect the wound and flaps.
Complications
Early Complications:
Hematoma
Seroma
Wound infection
Wound dehiscence
Partial or complete flap necrosis, particularly of the NAC or skin flaps
Axillary webbing
Persistent pain.
Late Complications:
Scar hypertrophy or keloid formation
Asymmetry
Loss of nipple sensation
Chronic lymphedema (if axillary dissection performed)
Unfavorable aesthetic outcome
Recurrence of disease
Implant-related complications if immediate reconstruction is performed.
Prevention Strategies:
Meticulous surgical technique with preservation of adequate vascularity to skin flaps
Careful hemostasis
Appropriate drain placement and management
Judicious use of compressive dressings
Patient education on postoperative care and activity restrictions
Prophylactic antibiotics
Careful assessment of patient comorbidities
Oncologic principles for margin control.
Prognosis
Factors Affecting Prognosis:
Stage of the cancer at diagnosis
Histological subtype and grade
Presence of lymph node metastasis
Response to neoadjuvant therapy (if applicable)
Margin status of the resection
Patient's overall health and adherence to treatment protocols.
Outcomes:
For oncologic indications, the prognosis is directly related to the stage of the cancer and the effectiveness of adjuvant therapies
For reduction mammoplasty, outcomes are generally excellent, with significant improvement in symptoms and breast shape
Aesthetic outcomes are dependent on surgical skill and patient healing, with scar appearance being a key factor.
Follow Up:
Regular follow-up appointments are essential for oncologic patients, including clinical examinations and imaging (mammography, ultrasound) to monitor for recurrence or metastasis
For aesthetic procedures, follow-up focuses on scar maturation, symmetry, and patient satisfaction
Long-term surveillance is crucial for early detection of any complications or recurrence.
Key Points
Exam Focus:
Wise pattern incision: IMF curvilinear extending superiorly
"keyhole" or "anchor" scar
Indications: Macromastia, ptosis with cancer, symptomatic gigantomastia
Key oncologic principle: Adequate resection with clear margins
Key aesthetic principle: Reshaping glandular tissue for mound formation and skin closure
Early complications: Flap necrosis, hematoma, seroma
Late complications: Scarring, asymmetry
Reconstruction options: Immediate/delayed, implant/autologous.
Clinical Pearls:
Preoperative marking is paramount for accurate dissection and symmetry
Preserve adequate flap thickness to ensure viability
Meticulous hemostasis prevents hematoma
Consider contralateral symmetrization for optimal aesthetic results
Discuss scar management openly with patients
it’s a significant aspect of patient satisfaction
Sentinel lymph node biopsy is standard for invasive breast cancer, even with mastectomy
Always confirm tumor margins radiologically and pathologically.
Common Mistakes:
Inadequate skin flap elevation leading to necrosis
Poor hemostasis causing hematoma/seroma
Insufficient glandular resection for oncologic safety
Overly aggressive dissection causing NAC devascularization
Neglecting contralateral symmetry leading to dissatisfaction
Underestimating the importance of postoperative compression and activity restriction
Not adequately counseling patients on scar appearance and potential complications.