Defining skin-sparing mastectomy surgical techniques: a narrative review

Introduction

Evolution

In 1991, the term “skin-sparing mastectomy” (SSM) was coined by Toth and Lappert; a technique that facilitated immediate reconstruction due to the advantages given by preservation of the uninvolved breast skin and of the inframammary fold. Toth and Kroll et al. published their experience using the same technique (1,2). This sparked a discussion on the balance between cosmetic results and local disease control. The story began earlier with Barton et al., who tested the hypothesis that SSM would have residual glandular tissue but found similar rates of glandular residue between prophylactic and therapeutic mastectomies (3). The era of SSM began with these concepts and post-mastectomy breast reconstructions (Figure 1) (1-3).

Figure 1 Evolution of SSM. SSM, skin-sparing mastectomy.

Definition

SSM is a surgical technique that involves making minimal incisions while preserving the widest possible coverage and the subcutaneous breast groove, aiming to remove any previous excision scars, or scarring caused by any diagnostic procedures. The same incision can be used to access the axilla for axillary dissection or sentinel-node biopsy. Additional incisions may be required to perform reconstructive procedures such as microsurgical axillary anastomosis (1,4,5). An added layer of complexity involves preserving the underlying subdermal plexus, which supplies the overlying breast skin, a crucial parameter for mastectomy skin flap survival. Failure to preserve this can result in skin flap necrosis and infection, leading to further complications such as implant loss if implants are used, or further operations for debridement and resurfacing. Some authors consider nipple-sparing mastectomy (NSM) a total SSM (6). Table 1 shows the difference between SSM with other types of mastectomies and their related procedures to clarify the difference between each type’s definition (6-8).

Classification

There are five different types of SSMs, which are summarized in Table 2 and Figure 2 (1,5,9,10).

Figure 2 SSM incision types: (A,B) incision type I; (C) incision type II; (D) incision type III; (E) incision type IV; (F) incision type IV. Permission to use the image obtained from reference (9). SSM, skin-sparing mastectomy.

Indications and oncological safety of SSM

The indications for SSM include ductal carcinoma in situ (DCIS), stage I–II infiltrating breast carcinomas, and local recurrences after conservative treatment (9). As stipulated by the 2023 US National Comprehensive Cancer Network guidelines, SSM and NSM are safe for patients with early-stage, biologically favorable invasive breast cancer or DCIS; imaging results indicate no nipple or skin involvement, clear nipple margins, and no nipple discharge or Paget’s disease (11-15). Several studies have demonstrated that SSM is associated with similar rates of local recurrence when compared to non-SSM interventions, with lower rates of distant relapse. A 2010 meta-analysis of nine studies, published between 1997 and 2009, comprising 3,739 patients, revealed no significant differences in the rates of local recurrence between SSM and non-SSM patients. However, the SSM group exhibited a lower percentage of distant relapses compared to the non-SSM group (16). Another meta-analysis of 20 studies involving 5,594 women with early-stage breast cancer found no differences in oncologic outcomes between SSM and conventional mastectomy without reconstruction (17). The data indicates that NSM and SSM are safe from an oncological perspective, provided that the indications are respected. The indications for conservative mastectomy may expand in the future, including patients after neoadjuvant chemotherapy. However, complications may be more frequent in these cases (17,18). In conclusion, SSM is an appropriate surgical option for patients with DCIS or stage I–II infiltrating breast carcinomas and some selected cases of stage III. However, patients with inflammatory or locally advanced carcinomas or smokers are less suitable candidates for SSM, with smoking being a relative contraindication requiring adaptation of the surgical technique (9). We present this article in accordance with the Narrative Review reporting checklist (available at https://abs.amegroups.org/article/view/10.21037/abs-23-19/rc).

Methods

Two independent authors searched for relevant studies on Medline (via PubMed), Cochrane Library, Web of Science, Google Scholar, Clinical Trials and Embase databases from January 1901 to February 2023. The search terms consisted of “skin-sparing mastectomy”, “surgical techniques”, “mastectomy”, “mastectomy techniques”, “mastectomy surgery”, “breast cancer surgery”, and “surgical oncology. The search strategy for PubMed was ((“Skin-Sparing Mastectomy”[Title/Abstract] OR “Mastectomy, Skin Sparing”[Title/Abstract] OR “Skin Sparing Surgery”[Title/Abstract]) AND (“Surgical Techniques”[Title/Abstract] OR “Mastectomy Techniques”[Title/Abstract] OR “Breast Cancer Surgical Techniques”[Title/Abstract] OR “Mastectomy Surgical Procedure”[Title/Abstract])). Additionally, the reference lists of previous reviews and relevant articles were manually checked.

Discussion

SSM surgical techniques

To achieve favorable results with minimal complications, it is important to consider the basic elements of this procedure. The initial step is to tailor the incision based on the presence or absence of scars from previous excisions, along with breast size and sagging (Figure 2) (1,5,9,10).

Type I SSM involves the creation of a 5mm or longer peri-areolar incision, with an optional second transverse incision in the axilla for axillary dissection or microsurgical anastomosis (1,5,9,10). In some cases, it may be necessary to extend the peri-areolar incision towards the axillar or 6 o’clock position to facilitate reconstruction (1,5,9,10). Conversely, type II SSM involves incorporating the existing scar and designing the incision accordingly to ensure continuity with the previous scar (1,5,9,10). Type III SSM involves the design of separate incisions for nipple-areola complex (NAC) removal and previous scars to create a “bridge” between the two skin margins, thereby preventing any potential loss of vitality that could result from overlapping (1,5,9,10). Types IV and V are utilized for sagging or ptotic breasts, where the goal is to correct any asymmetry with the contralateral breast. This can be accomplished via elliptical skin resection or incision methods, including the inverted “T” resection on both sides of the NAC (1,5,9,10).

In addition to Carlson’s well-described incision patterns, other authors have used different patterns (6). One example is the Hall-Findlay vertical reduction mammaplasty pattern, founded by Claude Lassus and Madeleine Lejour, which has recently been used for SSM with autologous immediate based reconstruction (IBR), such as latissimus dorsi (LD) and deep inferior epigastric perforator (DIEP) flaps (19). Some authors have also described endoscopic or video-assisted SSM with either IBR or LD flap-based IBR, using a lower axillary incision of 5–6 cm after sentinel lymph node biopsy or level I/II dissection through the same incision (20-23). Another instance is the Double Asymmetric Circular Incision, a new immediate breast reconstruction technique that appeared to be safe and easily reproducible in patients with small to medium-sized breasts and with little to moderate ptosis (24). The combination of SSM with free NAC transplantation is another increasingly popular surgical technique, which involves the removal of the NAC and reattaching it in a different location in a single operation, and reportedly boasts greater cosmetic quality than a secondary reconstruction.

A comprehensive explanation is necessary for the mastectomy flaps that have been dissected, as they are important for both the oncological and postoperative well-being aspects of the surgery. To prevent any damage with spacers, the dissection process must be accurate, and the flaps should have a uniform thickness. Flaps that are too thin do not improve oncological safety and have a higher probability of causing skin necrosis (25). According to the National Comprehensive Cancer Network guidelines, one randomized control trial has demonstrated the use of prophylactic topical 2% nitroglycerine to reduce mastectomy skin flap necrosis in both SSM and NSM (11-15).

Regarding anatomical differences among individuals, only 56% have a superficial layer of the superficial fascia that aids in dissection. The remaining 44% pose a challenge when using this surgical approach. Moreover, in both cases, a mammary gland may be located near the dermis, making it very challenging to remove all the breast tissue without damaging the flaps (26).

In the operating room, the surgeon needs to have the excised tissue evaluated by a pathologist to determine its positioning and conduct mammography, particularly in the breast tissue surrounding the tumor, to ensure no disease remains. If any disease is discovered, the surgeon must increase the amount of cutaneous resection. This assessment is especially critical for in situ carcinomas and can decrease the chances of local recurrence (27).

The four main techniques utilized for breast reconstruction include the transverse rectus abdominis muscle (TRAM) flap, a free microsurgical flap like the DIEP flap, anatomical expanders (temporary or permanent) with direct implants-less often recommended, and an extended LD flap or LD flap placed over an implant or expander (9).

Preservation of the underlying vasculature is paramount in mastectomies. Several studies have shown that the blood supply to the breast derives from the external and internal mammary arteries, the intercostal and thoraco-acromial arteries (28). Some authors therefore propose using lateral incisions, avoiding peri-areolar incisions due to increased skin traction, and limiting dissection to maintain the skin flap’s blood supply during mastectomies. Dissection using scissors with only point cauterization is also recommended to minimize the risk of thermal injury to the skin flaps (29). Others assert that while inframammary incisions offer more aesthetically pleasing scar outcomes, it may potentially compromise the inframammary vasculature (30). This assertion is evidenced by Proano and Perbeck’s study involving a cohort of 69 patients, where they discerned a substantial diminution in blood flow to an area 2 cm below the NAC in the group subjected to the inframammary approach (31). The boundaries of the dissection should be clearly understood by the oncologic surgeon. Most sources concur that to preserve as many feeding vessels as possible, skin flaps should be elevated to, but never exceed, the clavicle superiorly, the anterior axillary line laterally, or over the sternum medially (32). Dissection inferiorly should never transgress the inframammary fold. This tenuous region is devascularized even further when the inframammary fold needs to be recreated through the placement of deep sutures.

SSM complications and modifiable risk factors associated with complications

SSM can lead to several complications, such as infection, hematoma, and skin flap necrosis. Various factors increase the risk of skin flap necrosis, such as smoking, previous or adjuvant breast irradiation, diabetes, and a high body mass index (33). Prior research has shown that traditional mastectomies result in flap necrosis in 5.6–8% of cases, compared to 3–15% in SSM, varying according to the series examined (33,34). According to Sbitany et al., meticulous patient selection and surgical method optimization resulted in a surprisingly low flap necrosis rate (5.6%) (35).

Preventing necrosis in mastectomy flaps is crucial to ensure a satisfactory cosmetic outcome, particularly if an expander or implant is used for reconstruction. This complication can lead to implant extrusion and procedure failure (9). Avoiding necrosis requires careful preparation of the mastectomy flaps, including ensuring they are uniformly thick to prevent devitalization (9). Where there is extensive skin necrosis or necrosis with evidence of infection, surgical debridement and exploration may be necessary to prevent implant loss, regardless of whether muscular coverage was provided or not (9).

Assessing a patient’s smoking status is crucial to reduce the risk of necrosis due to its vasoconstrictive property affecting the skin (9). Additionally, it indirectly inhibits the release of catecholamines, which can reduce the production of capillary flow. Therefore, being a non-smoker is preferred (although smoking is only a relative contraindication) to reduce the risk of necrosis (9).

The planning and results of surgery are also affected by radiotherapy in many ways. If done before surgery, it may harm the final cosmetic outcome and raise the risk of problems like skin flap necrosis and wound breakdown (35). When used as an adjuvant treatment or for a local recurrence, it can also negatively impact the cosmetic result, depending on the reconstructive technique used (35). In general, when patients have previously undergone radiation and SSM, reconstructive techniques such as DIEP and TRAM flaps are preferred to improve outcomes and preserve skin to prevent necrosis. These procedures can help maintain cosmetic results (9,35).

Cosmetic outcome

The aesthetic benefits of SSM are difficult to examine scientifically. Still, we agree with other authors that this technique can improve the results of breast reconstruction by preserving the sub-mammary tissue and skin coverage (35-37). Previous research has shown that SSM can positively impact reconstruction outcomes, including correcting symmetry (35-37). For example, a study comparing TRAM flap with expander reconstructions, with and without SSM, found that a higher percentage of cases with SSM did not require correction of the contralateral breast (38). We believe that the procedure results demonstrate the best evidence for the aesthetic advantages of SSM in terms of reconstruction and symmetry.

Ideal time for reconstructions: immediate or delayed

Overview

The optimal timing and technique for breast reconstruction involves careful consideration of each patient’s unique circumstances and potential complications and risk (39). Breast reconstruction options include immediate reconstruction (performed simultaneously with mastectomy), delayed reconstruction (performed after completion of adjuvant treatment), and delayed-immediate reconstruction (involving tissue expansion during mastectomy and final reconstruction after adjuvant treatment) (39). A recent meta-analysis of 30 studies, involving approximately 14,000 patients, compared immediate and delayed reconstruction approaches and found that patients undergoing immediate reconstruction experienced more surgical complications, seroma, and infection. However, after conducting a sensitivity analysis on the subset of patients receiving post-mastectomy irradiation, no significant differences were found between the two groups (40). The advantages and contraindications of the immediate reconstruction approach are summarized in Table 3 (41).

Challenges and strategies for selecting the optimal timing and technique for breast reconstructive surgery

When considering breast reconstruction, various factors must be taken into account, such as cancer stage, tumor size and location, smoking status, axillary lymph node status, previous surgeries and radiotherapy, chemotherapy, pre-existing medical conditions, and patient preference (42,43). The primary concern with immediate breast reconstruction is the uncertainty of post-mastectomy radiotherapy, which can lead to significant risks and complications (42,44). Patients with stage I breast cancer, a favorable prognosis, a negative sentinel lymph node, and no requirement for axillary lymphadenectomy surgery or radiotherapy are typically advised to undergo immediate breast reconstruction (42). However, patients with stage II and III breast cancer are at high risk for postmastectomy radiotherapy and should undergo delayed or delayed-immediate breast reconstruction, per current guidelines (42). Despite this, some stage II patients may be able to receive immediate breast reconstruction if preoperative assessments, such as sentinel lymph node biopsy, are performed to more accurately determine their radiotherapy needs (45,46). There is controversy about whether to suggest radiotherapy based on the number of positive lymph nodes, given that a positive sentinel lymph node may be the only one identified in 85% of patients (45,47). Although these assessment methods are available, the necessity for radiotherapy can only be confirmed following conclusive pathological examination since the degree of tumor infiltration in the breast tissue is also a crucial factor (42).

Delayed-immediate reconstruction approach

In 2004, MD Anderson Cancer Center proposed a protocol for breast reconstruction and radiotherapy known as the “delayed-immediate reconstruction” for patients who may require radiotherapy following the final pathological examination (48). This protocol is primarily intended for patients with stage II breast cancer, one or more positive lymph nodes on biopsy, visible microcalcifications on mammography, and/or apparent multicentricity on ultrasonography (42,47). The delayed-immediate approach involves a SSM, followed by the placement of an expander in the subpectoral pocket (42,48). During radiotherapy, this expander is deflated and then expanded once more. Following tissue expansion, there is a waiting period of 4–6 months, after which breast reconstruction using an autologous flap and, if local conditions are acceptable, occasionally with a final implant, is performed (42,48). This protocol preserves the skin envelope and reduces complication rates from 38% for traditional delayed flap reconstruction to 26% for delayed-immediate reconstruction with an autologous flap (42,48). Furthermore, if the final pathological examination indicates that radiotherapy is unnecessary, a definitive breast implant can be inserted within a well-preserved skin envelope after tissue expansion (42,48,49).

Conclusions

SSM is a surgical procedure that has demonstrated favorable aesthetic results while providing optimal local cancer control; however, certain criteria must be met to ensure safety and efficacy. These criteria encompass the need for an experienced surgical team, a multidisciplinary evaluation process, the identification of suitable candidates, and the achievement of adequate margins. The procedure entails careful selection of the incision site and type, preservation of the cutaneous pocket and sub-mammary fold, and may lead to superior cosmetic outcomes. Additionally, this approach allows for immediate reconstruction following SSM which may decrease the need for additional reconstructive procedures.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://abs.amegroups.org/article/view/10.21037/abs-23-19/rc

Peer Review File: Available at https://abs.amegroups.org/article/view/10.21037/abs-23-19/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.org/article/view/10.21037/abs-23-19/coif). W.M.R. serves as an unpaid editorial board member of Annals of Breast Surgery from December 2023 to November 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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