Overview
Definition:
Skin-sparing mastectomy (SSM) is a surgical procedure that removes the entire breast tissue, including the nipple-areola complex, while preserving the overlying skin envelope for immediate or delayed reconstruction
This technique aims to achieve oncologic safety with optimal cosmetic results by minimizing skin excision and scar burden compared to traditional mastectomies.
Epidemiology:
SSM is increasingly performed for early-stage breast cancer and for prophylactic mastectomy in high-risk individuals
Its adoption has been driven by advances in oncoplastic surgery and breast reconstruction techniques, leading to improved patient satisfaction and quality of life
The selection of appropriate candidates is crucial for successful outcomes.
Clinical Significance:
SSM offers a significant advantage in terms of cosmetic outcome and patient acceptance by preserving the skin and subcutaneous tissue, thereby facilitating better breast mound reconstruction
It allows for a more natural-looking breast shape and can reduce the psychological impact of mastectomy
It is a cornerstone of modern breast cancer management for select patients.
Indications
Oncologic Indications:
Early-stage invasive breast cancer or ductal carcinoma in situ (DCIS) with limited skin involvement
Tumors located away from the nipple-areola complex
Inflammatory breast cancer is typically a contraindication
Multi-centric or diffuse DCIS may also be contraindications.
Prophylactic Indications:
High-risk patients for hereditary breast cancer (e.g., BRCA mutations) with no clinical or radiological evidence of cancer
Patients with a strong family history of breast cancer and significant personal risk factors.
Patient Factors:
Patient preference for breast conservation and reconstruction
Absence of significant comorbidities that would contraindicate prolonged surgery or reconstruction
Adequate skin quality and absence of prior radiation to the breast.
Contraindications:
Tumor involving the nipple-areola complex
Extensive Paget's disease of the nipple
Inflammatory breast cancer
Distant metastatic disease
Previous radiation therapy to the breast
Large tumor size relative to breast volume
Active smoking or other factors impairing wound healing.
Preoperative Preparation
Patient Counseling:
Thorough discussion of the procedure, potential risks, benefits, and alternatives
Detailed explanation of the reconstruction options (e.g., implant-based, autologous flap)
Informed consent regarding oncologic safety and cosmetic expectations.
Imaging And Biopsy:
Complete staging workup, including mammography, ultrasound, and potentially MRI of both breasts
Biopsy confirmation of malignancy or high-risk lesions
Sentinel lymph node biopsy planning.
Markings:
Precise marking of the planned skin incision to encompass the tumor or breast tissue while preserving adequate margins
Delineation of the nipple-areola complex to be excised
Planning for mastectomy flap thickness.
Anesthesia Considerations:
General anesthesia is typically required
Consideration for adjuncts like regional blocks for postoperative pain management
Assessment of patient's fitness for prolonged surgical time.
Procedure Steps
Incision And Skin Flaps:
Elliptical incision around the nipple-areola complex and encompassing the tumor if necessary, or a periareolar incision for prophylactic cases
Creation of bilateral skin flaps of adequate thickness (typically 0.5-1 cm) to ensure viability and preserve subcutaneous tissue, preserving the dermal vascular plexus.
Mastectomy And Specimen Removal:
Dissection of the breast tissue off the pectoralis major muscle
Careful removal of the entire breast parenchyma while maintaining the integrity of the overlying skin flaps
Specimen orientation for surgical pathology.
Lymph Node Dissection:
Performance of sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) as indicated by the oncologic staging and guidelines.
Reconstruction Placement:
Placement of an implant or tissue expander, or preparation for immediate autologous flap reconstruction, beneath the preserved skin flaps and muscle
Ensuring adequate coverage and hemostasis.
Closure:
Meticulous closure of the skin flaps in layers, often with drains placed to manage seroma formation
Consideration for cosmetic closure techniques.
Postoperative Care
Drain Management:
Monitoring and management of surgical drains
Drains are typically removed when output is minimal (e.g., < 30 ml/24h).
Pain Control:
Adequate analgesia, including multimodal approaches (opioids, NSAIDs, regional blocks) to manage incisional pain and discomfort
Early mobilization is encouraged.
Wound Care:
Regular dressing changes, monitoring for signs of infection, flap necrosis, or dehiscence
Education on self-care and activity restrictions.
Breast Prosthesis And Reconstruction:
Management of temporary external prostheses if reconstruction is delayed
Postoperative care related to the chosen reconstruction method (e.g., monitoring flap viability for autologous reconstruction, managing implant-related issues).
Adjuvant Therapy Planning:
Discussion and planning of adjuvant therapies (chemotherapy, radiation, endocrine therapy) based on final pathology results, in conjunction with the oncology team.
Complications
Early Complications:
Seroma formation
Hematoma
Wound infection
Skin flap necrosis
Nipple-areola complex viability issues.ymphoma
Drain site issues
Shoulder stiffness.
Late Complications:
Implant-related complications (rupture, capsular contracture, asymmetry)
Poor cosmetic outcome
Chronic pain
Lymphedema
Sensation loss
Scar hypertrophy.
Prevention Strategies:
Meticulous surgical technique, especially flap dissection and hemostasis
Judicious use of drains
Adequate patient selection and preoperative counseling
Postoperative antibiotic prophylaxis and early mobilization
Careful management of reconstruction to minimize tension on flaps.
Prognosis
Factors Affecting Prognosis:
Stage of cancer at diagnosis
Histological grade
Lymph node status
Receptor status (ER, PR, HER2)
Patient's overall health
Adherence to adjuvant therapies.
Outcomes:
For oncologic indications, the goal is to achieve oncologic safety comparable to traditional mastectomy, with reduced cosmetic deformity
For prophylactic cases, significant reduction in breast cancer risk is achieved
Patient satisfaction with cosmetic outcomes is generally high when appropriate candidates are selected.
Follow Up:
Regular follow-up appointments with the surgical and medical oncology teams
Clinical breast examinations
Mammography or MRI of the contralateral breast as per guidelines
Surveillance for local recurrence or new primary breast cancers.
Key Points
Exam Focus:
Indications and contraindications for SSM
Crucial difference between SSM and skin-sparing mastectomy with nipple preservation
Surgical steps and importance of flap viability
Management of complications, particularly flap necrosis and seroma
Role in oncoplastic surgery and prophylactic mastectomy.
Clinical Pearls:
Always ensure adequate margins and flap thickness
Counsel patients extensively on realistic cosmetic outcomes and potential for nipple sensation loss
SLNB is essential for oncologic staging
Reconstruction choice depends on patient factors and surgeon expertise.
Common Mistakes:
Inadequate flap thickness leading to necrosis
Excising too much tissue, negating cosmetic benefits
Failure to counsel adequately on nipple sensation loss
Inappropriate patient selection, especially those with contraindications
Ignoring sentinel node biopsy status.