Mastectomy Incision Research Articles

Prophylactic Mastectomy: Indications, Options, and Reconstructive Alternatives

Prophylactic mastectomy continues to be a controversial procedure as a preventive tool against breast cancer. Recent research and other scientific advances, however, have refocused attention on better risk estimation, evidence of efficacy, and improvements in reconstruction. The recently discovered genetic markers BRCA1 and BRCA2 have become increasingly important in determining risk; a BRCA1-positive patient's risk of developing breast cancer by the age of 65 is estimated at 50 percent to 80 percent. BRCA1- and BRCA2-positive breast cancers also tend to be higher grade and occur in younger women (making mammography less effective). Genetically linked breast cancers are usually estrogen receptor negative, making them less susceptible to chemoprevention. Various predictive models and recommendations by experts in the field are also available for today's clinicians to ascertain who should be genetically tested. The benefit of bilateral prophylactic mastectomy, although difficult to estimate, can be evaluated by looking at the incidence of breast cancer in studies of patients who have previously undergone prophylactic mastectomy. The estimated risk reduction from these studies is 80 percent to 95 percent. Similarly, life expectancy is believed to be increased from 2.9 to 5.3 years. The psychological benefits include a 70 percent rate of satisfaction and a decrease in emotional concern over developing breast cancer by 74 percent of women who underwent prophylactic mastectomy. Although reconstruction results may vary, most patients have been very satisfied and some may achieve cosmetic results that are better than their preoperative situation. Patient selection for specific types of reconstruction after prophylactic mastectomy and the decision to proceed should be based on surgical risk and the likelihood of a good outcome. The choice of mastectomy incision should consider the size of the breast, preexisting scars, patient risk factors, and the planned method and goal of reconstruction. The authors propose certain guidelines based on degree of ptosis and cup size when planning prophylactic mastectomies with reconstruction. In certain cases, a nipple-sparing mastectomy may provide cosmetic advantages that could outweigh the additional oncologic risk.

Reexamining Contraindications for Minimally Invasive Mitral Valve Surgery

Historically, contraindications to minimally invasive or robotic mitral valve surgery have included prior mastectomy, thoracic reconstruction, or chest radiation. However, we believe that by granting flexibility in the choice of skin incision site while performing careful dissection, surgeons can provide these patients the outstanding results afforded by a minithoracotomy. We present a patient who had undergone a prior mastectomy and radiation treatment in whom we performed a minimally invasive mitral valve repair through a right-sided minithoracotomy using the previous mastectomy incision.

Reexamining Contraindications for Minimally Invasive Mitral Valve Surgery

Historically, contraindications to minimally invasive or robotic mitral valve surgery have included prior mastectomy, thoracic reconstruction, or chest radiation. However, we believe that by granting flexibility in the choice of skin incision site while performing careful dissection, surgeons can provide these patients the outstanding results afforded by a minithoracotomy. We present a patient who had undergone a prior mastectomy and radiation treatment in whom we performed a minimally invasive mitral valve repair through a right-sided minithoracotomy using the previous mastectomy incision.

The Thoracoacromial Vessels as Recipient Vessels in Microsurgery and Supermicrosurgery: An Anatomical and Sonographic Study

The purpose of this study was to investigate the presence and the precise course of the pectoral branch of the thoracoacromial vessels on the underside of the pectoralis major muscle by anatomical dissection and by color Doppler ultrasound. A further goal was to determine whether these vessels were suitable as recipient vessels in microsurgery and supermicrosurgery for breast reconstruction. In 18 cadavers, the pectoral branch of the thoracoacromial vessels was followed caudally until the diameter of the artery diminished to 1 mm. The same examination was carried out in 40 young female volunteers by tracing the vessel course with color Doppler ultrasound. The 1-mm cutoff point of the artery was measured with reference to the manubrium, the midsternal line, the clavicle, and the upper border of the closest rib. In addition, in the cadavers, the 2-mm cutoff point was determined. At both cutoff points, the diameter of the accompanying vein was measured. The pectoral branch of the thoracoacromial vessels with the artery and concomitant veins could be detected on all 100 undersides of the pectoralis major muscle, anatomically and sonographically. In their course from the acromial region downward, the arteries reached a diameter of 1 mm at an average of 9.9 cm from the manubrium, horizontally 9.4 cm from the midsternal line, and vertically 4.0 cm from the lower border of the clavicle. The 1-mm reference point was situated on the upper border of the third rib in 85 percent of cases. The average distance between the 1-mm and the 2-mm cutoff points was 3.5 cm. At the 1-mm cutoff point, the diameter of the vein was 0.9 mm, and at the 2-mm cutoff point, it was 1.7 mm. Because of their central position at the anterior hemithorax, these vessels are easily accessible from mastectomy incisions, even in skin-sparing mastectomies; the donor-site morbidity is negligible; and as the diameters of the vessels gradually decrease along their caudal course, the recipient site can be chosen precisely according to the length and the diameter of the donor vessels and major mismatch can be avoided. Thus, the pectoral branches of the thoracoacromial vessels are well suited as recipient vessels for (super)microsurgery and are a very promising addendum to the thoracodorsal and internal mammary vessels.

Postmastectomy radiotherapy: Patterns of recurrence and long-term disease control using electrons

Purpose To determine the patterns of failure and prognostic factors for locoregional recurrence after postmastectomy radiotherapy (RT), using a specific electron beam technique. Methods and materials A uniform electron beam was used in 323 patients with invasive breast cancer at the University of Florida Health Science Center. The patterns of disease recurrence, prognostic factors, and overall outcome were studied. Results At 10 years, the freedom from locoregional recurrence, disease-free survival, and absolute survival rate was 90%, 62%, and 55%, respectively. The 10-year disease-free survival rate for patients with 0, 1–3, and >3 positive lymph nodes was 73%, 75%, and 47%, respectively. On multivariate analysis, the three factors significantly associated with locoregional recurrence were T stage, number of involved nodes, and RT fields. Full axillary fields appeared to be beneficial ( p = 0.02). Patients with positive surgical margins appeared to benefit from a mastectomy incision boost to ≥65 Gy. Finally, patients with T2N0 disease had a substantial risk of chest wall recurrence without chest wall RT. Conclusion Findings include a low rate of clinically detectable locoregional recurrence. The data suggest benefits for the addition of full axillary RT in node-positive patients and chest wall RT in patients with T2N0 disease.

Tear-drop incision for mastectomy to avoid dog-ear deformity.

Tear-drop incision for mastectomy to avoid dog-ear deformity.

Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction.

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate postmastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7 percent. The late complication rate (> 2 months) was 23 percent, with a pathological capsular contracture rate of 11 percent at 2 years and 15 percent at 5 years and an implant removal rate of 7 percent. The revisional surgery rate was 30.2 percent. The cosmetic results were assessed prospectively using an objective five-point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorated in a linear fashion, from an initial acceptable result of 86 percent 2 years after patients completed their reconstruction to only 54 percent at 5 years. This decline in cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patients were irradiated. Upon Cox model analysis, pathological capsular contracture was the only factor that contributed significantly to a poor cosmetic outcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of the patients without capsular contracture who demonstrated deterioration in their cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis with aging.

Submuscular periareolar approach to augmentation mammoplasty in Korean women.

Augmentation mammoplasty can be approached by various methods according to the type of implant and implantation site depending on the status of the patient or surgeon's preference. The advantage for submuscular placement is based on problems associated with subglandular placement, especially capsular contracture and sensory changes in the nipple, and interference with the interpretation of mammograms is avoided. There are fewer complications such as hematoma, infection, and extrusion of the implant with submuscular dissection and relatively avascular, minimal sensory changes in the nipple compared with subglandular approach. The submuscular periareolar approach to augmentation mammoplasty was first described in the 1970s. This approach provides easy access to both the subglandular and subpectoral planes. It also provides a central point of access for creation of the implant pocket, which allows for easier and more accurate dissection in all diameters. The resultant periareolar scar is usually minimal with less injury to breast parenchyme and eventual biopsy or mastectomy incision to be performed through or around the areola. During the period of March 1999 to January 2000, 19 cases of who received submuscular periareolar augmentation mammoplasty under general anesthesia resulted in favorable scars with accurate access to pocket margin, easier dissection, and less bleeding compared with submuscular transaxillary augmentation mammoplasty. In our experience with the submuscular periareolar approach to breast augmentation it was highly versatile, safe, and less painful; postoperative hematoma incidence was greatly reduced and breast tissue injury was minimized.

Immediate Breast Reconstruction for Breast Carcinoma Using the Periareolar Approach

Skin-sparing mastectomy with immediate breast reconstruction has shown to be oncologically safe while providing dependable aesthetic results. However, flap inset into the skin defect of the excised biopsy site and nippleareola complex often results in a patchlike effect and transverse scars. By keeping the mastectomy incision solely around the areola, all breast skin can be preserved. Thus, in immediate breast reconstruction with replacement of the nipple and areola by a small skin island from a deepithelialized TRAM flap or latissimus dorsi muscle flap, the scar is kept at the natural border between areola and breast skin. Reconstruction of the nipple-areola complex further helps to camouflage the incision line. This may result in the best possible aesthetic outcome after mastectomy to date. The technique has been used in 17 breast cancer patients (intraductal cancer, n = 5; T1/T2 ductal cancer, n = 13) with good to excellent results. No local or distant recurrences have been seen; however, mean follow-up time is short (10 months). As the procedure of choice, a free TRAM flap was performed in nine patients for immediate reconstruction. The other eight patients were too slim for an autologous reconstruction; therefore, a latissimus dorsi muscle flap with a small skin island and a silicone implant were used. There were no major complications in either group. In contrast to traditional skin-sparing mastectomy, all breast skin is preserved with the periareolar approach. Therefore, special surgical expertise is required to ensure tumor free margins, especially with respect to the skin overlying the tumor. If these requirements are met, excellent results in breast reconstruction are amenable with adequate oncologic safety. (Plast. Reconstr. Surg. 101: 1228, 1998.)

Immediate breast reconstruction for breast carcinoma using the periareolar approach.

Skin-sparing mastectomy with immediate breast reconstruction has shown to be oncologically safe while providing dependable aesthetic results. However, flap inset into the skin defect of the excised biopsy site and nipple-areola complex often results in a patchlike effect and transverse scars. By keeping the mastectomy incision solely around the areola, all breast skin can be preserved. Thus, in immediate breast reconstruction with replacement of the nipple and areola by a small skin island from a deepithelialized TRAM flap or latissimus dorsi muscle flap, the scar is kept at the natural border between areola and breast skin. Reconstruction of the nipple-areola complex further helps to camouflage the incision line. This may result in the best possible aesthetic outcome after mastectomy to date. The technique has been used in 17 breast cancer patients (intraductal cancer, n = 5; T1/T2 ductal cancer, n = 13) with good to excellent results. No local or distant recurrences have been seen; however, mean follow-up time is short (10 months). As the procedure of choice, a free TRAM flap was performed in nine patients for immediate reconstruction. The other eight patients were too slim for an autologous reconstruction; therefore, a latissimus dorsi muscle flap with a small skin island and a silicone implant were used. There were no major complications in either group. In contrast to traditional skin-sparing mastectomy, all breast skin is preserved with the periareolar approach. Therefore, special surgical expertise is required to ensure tumor free margins, especially with respect to the skin overlying the tumor. If these requirements are met, excellent results in breast reconstruction are amenable with adequate oncologic safety.

Immediate TRAM Flap Reconstruction of the Breast after Mastectomy for Cancer: A Thai Experience

: From January 1990 to June 1995, immediate transverse rectus abdominis myocutaneous (TRAM) flap reconstruction of the breast after mastectomy for cancer was performed in 40 patients with the objective of improving the quality of life. The 40 cases included one malignant cystosarcoma phyllodes (MCP), two intraductal carcinomas, four mucinous carcinomas (T1–2 NO), one lobular carcinoma (T2N1), and 32 invasive ductal carcinomas (T1–2 NO = 19, T3NO = 1, T1–2N1 = 9, T3N1 = 3). Modified radical mastectomy (MRM) was performed in all but one patient (MCP) who had subcutaneous mastectomy. A single pedicle TRAM flap was used for breast reconstruction in 36 cases and double pedicles in the remaining four cases. Since mid-1991, the mastectomy incision has been modified from elliptical incision to new skin-sparing incisions of various patterns depending on the tumor sites (n= 30). This change permitted a better cosmetic result and lessened the paresthetic area of the breast. Major complications were found in only 6 cases (20% skin flap necrosis in 1, major fat necrosis with discharge in 3, wound infection with foreign body in 1, and abdominal wound dehiscence in 1 case). The average postoperative hospital stay was 9 days (5–23 days). Adjuvant chemotherapy was given in 22 cases. All but two cases received the treatment within 1 month postoperatively (PO). Subsequent nipple reconstruction was accomplished in 18 cases using local skin flap in 16 and nipple sharing in 2 patients. There were two deaths from distant metastasis (one also had local chest wall recurrence). In the other cases no evidence of disease was found. The follow-up periods ranged from 6 to 72 months. From our experience so far, we have found that, in early breast cancer patients, MRM with a skin-sparing incision and immediate TRAM flap reconstruction does not compromise the oncological sound, but improves the cosmetic result, provided that the patients receive a full course of treatment as planned.

Breast Conservation Therapy: Role, Techniques, and Controversies?A Personal Approach

: Within this generation, the management of breast cancer has evolved from a single operation, mastectomy, to the use of radiation following wide local excision and axillary lymphadenectomy for selected patients. Both treatment options are appropriate in some patients, but there remain patients for whom mastectomy is the preferable treatment. Conversely, there are patients for whom radiation offers a better alternative. This article attempts to define criteria for treatment selection. Patients with the following tumor characteristics are better treated by mastectomy than radiation: (a) diffuse malignant calcifications within the breast; (b) multicentric cancer; (c) large cancers with respect to the size of the breast; and (d) more than one tumor in the same breast. Other patients may be best suited for radiation therapy, such as those with inner-quadrant lesions close to the underlying pectoralis major muscle, or those patients with eccentrically located tumors, such that the mastectomy incision might be compromised by this location. Clear surgical margins are desirable at the local excision site. Axillary dissection generally includes levels I and II nodes, but there are occasions when a lesser dissection, even none, may be appropriate. The treatment of women with breast cancer requires exquisite surgical judgment to balance the desire to retain the breast with the scientific principles that will minimize the chances of local recurrence.

Modified mastectomy incision for eccentric biopsy sites

Modified mastectomy incision for eccentric biopsy sites

Improved aesthetics in breast reconstruction: modified mastectomy incision and immediate autologous tissue reconstruction.

A common detraction from the aesthetic results of breast reconstruction is the presence of a transverse mastectomy scar and the patch-like effect of the paler abdominal skin contrasting with the thoracic skin. The technique described involves a modified mastectomy approach in which the breast parenchyma and nipple are first mobilized through a periareolar incision and then removed, along with the axillary lymph nodes, through an axillary counter-incision. A de-epithelialized transverse rectus abdominis musculocutaneous flap is then used to fill the empty "skin brassiere," effectively replacing the glandular defect, and a small patch of skin is exteriorized to match the areolar defect. Excellent symmetry can be attained usually without having to manipulate the opposite breast. After nipple-areolar reconstruction, the breast looks quite normal without the usual stigmas of mastectomy. In 21 breast reconstructions performed since 1991, there has been no incidence of skin flap necrosis or local recurrence.

Application and modification of the circular skin excision and pursestring procedures.

The concept of the circular excision is not new. However, it was complicated by excessive postoperative areolar stretching and scar hypertrophy. The Benelli principle of a permanent subdermal pursestring suture overcame these drawbacks. We present our experiences with the circular skin excision for mastopexy procedures and for circular skin incision for total mastectomy and immediate reconstruction.

The impact of breast cancer on patients and husbands

The purpose of this descriptive study was fourfold: (a) to assess the adjustment concerns of patients and husbands after a mastectomy, (b) to describe their reactions to seeing the mastectomy incision, (c) to determine which phase of illness was most stressful for them, and (d) to identify factors that helped them cope with the illness. Tape-recorded interviews were conducted with 50 mastectomy patients and their husbands in the hospital just after surgery and 1 month later. Transcripts were content analyzed by two independent raters. Results indicated that survival concerns were the predominant worries reported by patients and husbands in the hospital and 1 month after surgery. Although most of the husbands reacted well to seeing their wives' mastectomy incision, a small group of husbands reported that it was a difficult experience. Patients and husbands indicated that emotional support, information, attitude, and religion were the factors that helped them cope with the illness during this time.

Breast reconstruction with submuscular prosthesis after modified radical or simple mastectomy. Surgical technique and early complications.

A series of 100 women who underwent breast reconstruction is reviewed. They had previously been treated for breast cancer with modified radical or simple mastectomy. The technique and early results of reconstruction are presented. The same surgeon performed all these operations and the technique was not varied. Emotional need for reconstruction was the main factor in patient selection. The interval between mastectomy and reconstruction was as a rule at least one year after removal of stage I cancer and 2-5 years in stage II cases. Scar correction was required significantly more often after oblique than after horizontal mastectomy incision. A submuscular pocket was created to accommodate the prosthesis and a muscle and fascia flap was used to add tissue and contour. No major early complications occurred. The submuscular implantation of prosthesis facilitated clinical follow-up. In a background population of breast cancer patients, the overall frequency of breast reconstruction was 4%. The figure for premenopausal patients with stage I breast cancer treated with modified radical mastectomy was 18%.

Subcutaneous mastectomy for juvenile hypertrophy of the breast: report of a case

Massive juvenile hypertrophy of the breast in a 12-year-old girl was successfully treated with a primary subcutaneous mastectomy and secondary placement of gel-filled silastic implants. The patient weighed 114 pounds and her breasts weighed15/12 pounds. Small foci of regrowth occurred at the lateral ends of the mastectomy incisions only; a total of five of these foci were removed. Six years later no evidence of further residual breast tissue was noted and the breasts have been satisfactorily reconstructed.

New Closure for Radical Mastectomy Incisions

New Closure for Radical Mastectomy Incisions

Application of the Z-plasty principle to closure of radical mastectomy incisions.

Application of the Z-plasty principle to closure of radical mastectomy incisions.