Skin-sparing mastectomy: benefits and problems 

Dick Rainsbury, consultant at  Westminster Hospital, Winchester

(1) What are the technical problems of skin-sparing mastectomy?    There are two main problems with this approach.   Firstly, as the operation is generally done through a small either central circular incision around the areola or through a small elliptical incision, access is somewhat limited by the size of the incision.   With careful technique, excellent lighting and equipment, the procedure can be greatly simplified.  The use of extensive subcutaneous infiltration with adrenaline/saline solution, good cutting and coagulation equipment, a high quality headlight and atraumatic retractors greatly facilitates the procedure, and enables good visualisation of the optical cavity created by skin-sparing mastectomy.  It is normally perfectly feasible to approach the axilla through the central incision in the skin envelope, rather than having to carry out a separate axillary incision.   Secondly, because the skin flaps are long and thin, there can be a problem with the blood supply of the most distal part of the flap.  This typically affects the medial and lateral poles of the skin envelope.  This problem can be minimised by careful handling and retraction of the skin flaps, by avoiding flaps which are too thin, and by avoiding the operation in patients who are smokers.  A number of studies show that the risks of skin flap ischaemia and necrosis are highest in smokers, and this group of patients should be offered non-skin-sparing mastectomy instead.

(2)   What are the indications for skin-sparing mastectomy?  Traditionally the operation has been offered to three groups of patients.   Firstly, in those undergoing risk-reducing mastectomy, with no established disease.  Secondly, in patients with DCIS.  Thirdly, in patients with early invasive cancer.  Most of the published series relate to the use of skin-sparing mastectomy in patients with early localised malignancy or pre-malignancy, but there are a few studies reporting its use in patients with more advanced disease.  There is a theoretical risk in these patients that there will be a higher incidence of local recurrence in the overlying skin, although to date there is no clear evidence that these risks are higher than in patients undergoing conventional non-skin sparing mastectomy.  The skin-sparing mastectomy is especially indicated in patients undergoing immediate breast reconstruction, as preservation of the entire skin envelope allows reconstruction of the breast within the normal anatomical confines of the breast, resulting in good shape, size, symmetry and ptosis.  If skin-sparing mastectomy is carried out in patient expecting delayed reconstruction, this may lead to suboptimal cosmetic results, as the skin envelope tends to contract and produce ugly wrinkling and distortion.

(3)   What are the contraindications for skin-sparing mastectomy?   The main contraindications are in patients at risk for ischaemia, particularly smokers.  It is also contraindicated in patients with locally advanced disease, when preservation of skin will increase the risks of incomplete excision of the disease and troublesome local recurrence.  Skin-sparing mastectomy can be used in salvage procedures, such as mastectomy following local recurrence in patients who have undergone breast-conserving surgery and radiotherapy.  In these patients, care needs to be taken to leave reasonably thick skin flaps, in order to ensure a satisfactory blood supply to the ends of the skin flaps.

(4)   What are the benefits, the complications and the outcomes of skin-sparing mastectomy?   The main benefits of skin-sparing mastectomy are the reduction in scarring (when carried out through a circular central incision, the scar can be hidden by subsequent overlying nipple/areola reconstruction), excellent shape, size, symmetry and ptosis, and a reduced need for contralateral procedures to achieve symmetry.  The complications of skin-sparing mastectomy relate to ischaemic skin necrosis in patients at risk and a theoretical risk of local recurrence in patients with more advanced disease.

(5)   What do you think about delayed nipple-sparing modified subcutaneous mastectomy?   This is a useful operation for patients wishing to preserve the nipple.  Providing the tumour is > 2 cm away from the nipple/areola complex, there is little evidence to show that it increases the risks of recurrence in the region of the nipple.  Recent studies have shown the benefits of pre-operative core biopsy of the sub-areola region in patients wishing to have nipple preservation.  If these biopsies show no evidence of disease in the major lactiferous ducts, it appears to be safe to go ahead with nipple-preserving mastectomy.