Abstract
Introduction: Post-mastectomy reconstruction in patients with severe breast ptosis can be challenging. Traditionally, a skin sparing mastectomy (SSM) with a circumareolar incision or a horizontal elliptical extension results in a long, horizontally-oriented scar in the central breast. The Wise pattern SSM with an inferiorly-based dermal flap addresses skin redundancy and provides added vascularized implant coverage in ptotic patients with macromastia. The purpose of this study is to compare outcomes in ptotic patients undergoing SSM with Wise pattern and a modified vertical technique which also uses de-epithelialized excess skin under the incision. Methods: A retrospective chart review was performed on patients that underwent SSM using a Wise or vertical skin reducing technique. The Wise pattern was performed using an inferiorly-based dermal flap and the vertical method used a laterally-based dermal flap covering the implant/tissue expander (TE). Results: SSM with the use of autoderm was performed in 42 patients (67 breasts) using either the Wise (n = 49 breasts) or vertical (n = 18 breasts) method. Both groups had similar BMI (35.4). The prepectoral plane was used in 93.5% of Wise pattern patients and all vertical patients. All cases of seroma and hematoma occurred in the Wise pattern group (10.2%). Mastectomy skin necrosis requiring unplanned return to surgery for debridement occurred in 20.4% of those undergoing Wise pattern SSM and 11.1% undergoing the vertical pattern (p = 0.49). Conclusion: Severely ptotic patients undergoing SSM have a high risk of skin necrosis. A dermal flap under the closure has the advantage of vascularized tissue reinforcing the wound in implant based reconstruction. The vertical pattern SSM using a laterally-based dermal flap may be a safe, simple alternative to the Wise pattern in select patients.
Keywords: ptosis, breast cancer, mastectomy, implant, tissue expander, reconstuction
Résumé
Introduction : La reconstruction postmastectomie chez des patientes ayant une ptose importante peut être difficile. Traditionnellement, une mastectomie avec épargne cutanée (SSM) et une incision périaréolaire ou une incision horizontale elliptique aboutissent à une longue cicatrice horizontale au centre du sein. La SSM utilisant le patron de Wise avec un lambeau dermique à base inférieure résout l’excès de peau et fournit une couverture vascularisée supplémentaire de l’implant chez les patientes ayant une ptose avec macromastie. Le but de cette étude est de comparer les résultats chez des patientes avec ptose mammaire subissant une SSM avec schéma de Wise et les résultats d’une technique verticale modifiée qui utilise également la peau en excès dé-épithélialisée sous l’incision. Méthodes : Une revue rétrospective des dossiers de patientes ayant subi une SSM avec schéma de Wise ou avec technique de réduction cutanée verticale a été réalisée. Le schéma de Wise a été exécuté en utilisant un lambeau dermique à base inférieure et la méthode verticale a utilisé un lambeau dermique à base latérale couvrant l’implant ou l’expanseur tissulaire. Résultats : Une SSM avec l’utilisation d’un autoderm a été réalisée chez 42 patientes (67 seins) selon la méthode de Wise (n = 49 seins) ou la méthode verticale (n = 18 seins). L’IMC était similaire dans les deux groupes (35,4). Le plan prépectoral a été utilisé chez 93,5% des patientes du schéma Wise et chez toutes les patientes de la méthode verticale. Tous les cas de sérome et d’hématome ont été observés dans le groupe utilisant le schéma de Wise (10,2%). Une nécrose cutanée de la mastectomie nécessitant une reprise chirurgicale non prévue pour débridement est survenue chez 20,4% des patientes ayant subi une SSM avec le schéma de Wise et 11,1% des patientes ayant bénéficié de la méthode verticale (p = 0,49). Conclusion : Les patientes ayant une ptose sévère et subissant une SSM ont un risque élevé de nécrose cutanée. Un lambeau dermique sous la fermeture présente l’avantage d’un tissu vascularisé renfonçant la plaie dans la reconstruction basée sur un implant. Une SSM utilisant la méthode verticale et un lambeau dermique à base latérale peut être une méthode de remplacement simple et sécuritaire au schéma de Wise chez des patientes sélectionnées.
Mots-clés: Ptose, cancer du sein, mastectomie, implant, expanseur tissulaire, reconstruction
Introduction
Patients with severe breast ptosis who undergo mastectomy with immediate implant-based reconstruction can pose a reconstructive challenge. 1 Nipple sparing mastectomy has been described in patients with mild-moderate ptosis. 2 Nipple removal with skin sparing mastectomy (SSM) is typically necessary with severe grade II-grade III ptosis. Excess skin must be managed to optimize contour and shape of the reconstruction. Traditionally, a SSM with a circumareolar incision or a horizontal elliptical extension results in a long, horizontally oriented scar in the central breast.3,4 Disadvantages of this incisional pattern are central flattening and widening of the appearance of the breast with a horizontal scar that is often visible to the patient from the birds-eye-view and in certain clothing. 5 The Wise pattern SSM with an inferiorly-based dermal skin flap, sometimes referred to as “autoderm,” addresses skin redundancy and gives added vascularized implant coverage in ptotic patients with macromastia.3,6–15 The autoderm can be particularly favorable in pre-pectoral reconstruction given the high risk of implant exposure in the event of skin dehiscence. Wise pattern SSM provides better projection and overall cosmesis than that of the traditional horizontal elliptical incision. However, post-operative wound healing complications, particularly at the intersection of the vertical and inframammary incisions (“T-point”), have been described.3,6–8,16 The additional incisions decrease mastectomy skin flap dermal perfusion potentially increasing mastectomy skin necrosis.4,6,8
The vertical pattern mastopexy design can be adapted for SSM to address skin redundancy. An advantage of the vertical incision pattern is reduction of scars with one continuous scar. 17 Without the susceptible T-point, the vertical incision SSM may be associated with fewer complications compared to the Wise pattern. We have modified the vertical SSM to utilize excess skin as a laterally-based dermal flap for partial vascularized coverage of the implant. No study has directly compared these two skin-reducing mastectomy techniques which utilize excess skin as vascularized dermis to cover the implant. The purpose of this study was to compare outcomes of the Wise pattern and a modified vertical pattern SSM autoderm techniques in severely ptotic patients.
Methods
A retrospective chart review was performed on patients at the institution undergoing implant-based reconstruction between 2019 and 2022. Patients that underwent SSM using either a Wise pattern or vertical skin reducing technique were included. Patients that underwent nipple sparing mastectomy were excluded. Patient demographics (age, body mass index (BMI), procedure laterality) and comorbidities were recorded. Implant plane position (pre-pectoral or submuscular plane) was assessed. Outcome variables of interest included as delayed wound healing, infection, seroma and hematoma formation, TE/implant removal and revision were recorded for each patient.
All statistical calculations were performed with Excel 2023 Analysis Toolkit Package besides standard descriptive statistical calculations, such as mean and standard deviation. T-test was used in comparison of groups for continuous variables. Binary variables were evaluated using a chi-square test. A p-value of <0.05 was considered statistically significant.
Surgical Technique
The mastectomy incision patterns are marked preoperatively in communication with the oncological breast surgeon. Tumor location and existing scars are considered in planning. Markings are made to remove the nipple areola complex (NAC) for SSM. A Wise pattern approach skin reducing mastectomy has been described previously. 16 Our modifications compared to a standard Wise pattern are to perform conservative markings to minimize tension on the mastectomy skin flaps. A triangle incorporating the nipple with 6-8 cm limbs is marked with lines extending from the triangle toward IMF medially and laterally (Figure 1). The breast surgeon may remove the triangle with the nipple and make the medial and lateral incisions for the mastectomy. The remaining entire inferior skin (not just a standard 8-10 cm inferior pedicle) is de-epithelialized as dermal flap and used to cover the implant or tissue expander with or without mesh. When mesh is used for prepectoral reconstruction, the dermal flap can provide anterior implant coverage with the autoderm over the mesh or the mesh can be bridged superiorly in continuity with the autoderm (Figure. 2).
Figure 1.
Skin reducing skin sparing mastectomy techniques. (A) Preoperative markings for standard circumareolar skin sparing mastectomy in a ptotic patient. (B) Excision of nipple and adjacent dog ears for linear closure. (C) Linear closure results in central flattening and long horizontal central breast skin with a length dependent on amount of ptosis. (D) Preoperative markings for Wise pattern skin reducing mastectomy. A triangle incorporating the nipple with 6-8 cm limbs is marked with the triangle extending to the IMF medially and laterally. (E) The oncological breast surgeon excises the triangle with the nipple and the lateral limbs to the IMF for exposure for mastectomy. The inferiorly based skin is de-epithelialized as a dermal flap (orange) can be placed over the implant. (F) Wise pattern scar results. (G) Markings for the vertical skin sparing technique. (H) The nipple is excised and a medial curvilinear incision can be made by the breast surgeon for greater exposure. The skin between the medial vertical incision the area that the lateral vertical incision would be made in a vertical mastopexy is de-epithelialized. This leaves a laterally based dermal flap that can drape over the implant (I) The resultant vertical scar with a lateral j-extension by the inframammary fold.
Figure 2.
Wise pattern skin sparing mastectomy. (Left) De-epithelialized skin used as autologous dermal flap overlying mesh and tissue expander. (Right) Wise pattern skin sparing mastectomy immediately following closure.
Vertical SSM mastectomy is designed with a superior 16 cm length dome or semicircle at the level of the existing nipple or slightly above rather than at Pitanguy's point. This limits the superior limit of the vertical scar, as designing a standard vertical approach based on Pitanguy's point may result in a vertical scar that appears too high following SSM with reconstruction. Two conservative vertical curvilinear extensions are made that converge 2 cm above the IMF. The oncological breast surgeon excises the nipple through the superior dome and may use the medial curvilinear vertical incision for greater exposure for the mastectomy (Figure 3). We have found that using the medial vertical incision with the periareolar incision gives the breast surgeon greater exposure and potentially ease of dissection. If the breast surgeon only uses the periareolar incision, the medial vertical incision is still made during tissue expander placement. This allows for draping of the laterally based dermal flap without imbricating the de-epithelialized skin, which would give excessive fullness in the lower pole. The lateral curvilinear vertical incision can be adjusted to minimize excess tension, and the skin between those incisions is de-epithelialized and used as a dermal flap to cover the inferior, anterior portion of the tissue expander or implant.
Figure 3.
Vertical pattern skin sparing mastectomy. (Left) De-epithelialized skin at the inferior pole of the breast between converging medial and lateral curvilinear vertical incisions. (Middle) De-epithelialized skin used as autologous dermal flap covering inferior, anterior portion of subpectoral tissue expander. (Right) Vertical pattern skin sparing mastectomy immediately following closure.
Mesh can be used to bridge the uncovered portion of the implant and is inset in continuity with the dermal flap. Tissue expanders or implants are immediately placed typically in the pre-pectoral plane but can be placed subpectorally as well. We have found that most prepectoral plane reconstruction patients benefit from fat grafting in the upper pole secondarily to fill the superior pole deficiency. Because prepectoral patients with direct to implant reconstruction typically have a second stage for fat grafting, we favor placing tissue expanders partially filled in an attempt to minimize skin necrosis.
Results
Forty-two patients (n = 67 breasts) underwent skin-reducing, SSM with immediate placement of a tissue expander or implant using the Wise or vertical pattern methods. All patients had severe Grade II ptosis or Grade III ptosis pre-operatively. Thirty-one patients (n = 49 breasts) were included in the Wise pattern group and 11 patients (n = 18 breasts) in the vertical pattern group (Figures. 4 and 5). Bilateral reconstruction occurred in 58.1% of Wise pattern patients and 63.64% of vertical patients. Tissue expanders were immediately placed in 83.87% of Wise pattern patients and 81.82% of vertical patients. Patient characteristics and comorbidities are described in Table 1 below. The Wise and vertical groups had no statistically significant difference in age, incidence of cardiac disease, connective tissue disease, and smoking history. Wise pattern average BMI was 35.96 ± 8.2, while average BMI for the vertical group was 33.91 ± 6.4. Obesity (BMI > 30 kg/m2) was present in 74.2% of the Wise group and 63.6% of vertical patients. The prepectoral plane was used in 93.5% of Wise pattern patients and all vertical patients.
Figure 4.
Vertical mastectomy method. (Top) Preoperative patient with macromastia and severe breast ptosis. (Bottom) 2 years following vertical skin sparing mastectomy with immediate tissue expander reconstruction and 4 months following breast reconstruction revision.
Figure 5.
Wise pattern skin sparing mastectomy method. (Top Left) Preoperative patient with macromastia and severe breast ptosis. (Top Middle and Bottom Left) Skin flaps following wise pattern skin sparing mastectomy. (Top Right) De-epithelialized inferior skin flap. (Bottom Middle) Prepectoral tissue expander with overlying mesh sitting in breast pocket. (Bottom Right) 6 months postoperative following Wise pattern skin sparing mastectomy and direct to implant reconstruction with no revisions.
Table 1.
Skin Sparing Mastectomy Patient Characteristics and Comorbidities.
| Skin sparing mastectomy technique | No. of Patients | Mean age (years) | Cardiac disease | Connective tissue disease | Diabetes | Smoking | BMI Kg/m2 | BMI > 30 |
|---|---|---|---|---|---|---|---|---|
| Wise | 31 | 51.87 ± 11.66 | 12 (38.7%) | 2 (6.4%) | 8 (25.8%) | 3 (9.7%) | 35.96 ± 8.20 | 23 (74.2%) |
| Vertical | 11 | 50.55 ± 8.98 | 7 (63.6%) | 0 (0.0%) | 1 (9.1%) | 0 (0.0%) | 33.91 ± 6.41 | 7 (63.6%) |
| Total | 42 | 51.52 ± 10.93 | 19 (46.3%) | 2 (4.9%) | 9 (21.4%) | 3 (7.1%) | 35.43 ± 7.75 | 30 (71.4%) |
The complication information for each cohort is represented in Table 2 below. All cases of seroma and hematoma occurred in the Wise pattern group (10.2%). Mastectomy skin necrosis requiring debridement occurred in 20.4% of those undergoing Wise pattern SSM and 11.1% in the vertical group (p = 0.49). Implant infection requiring antibiotics occurred in 14.3% of Wise pattern patients and 11.1% of vertical pattern patients (p = 0.43) Neither infection rates nor revision rates had a significant difference between groups.
Table 2.
Summary of Complications.
| Skin sparing mastectomy technique | No. of TE/Implants | Hematoma | Seroma | Skin Necrosis Requiring Debridement | Infection Requiring Antibiotics |
|---|---|---|---|---|---|
| Wise | 49 | 5 (10.2%) | 5 (10.2%) | 10 (20.4%) | 7 (14.3%) |
| Vertical | 18 | 0 | 0 | 2 (11.1%) | 2 (11.1%) |
| Total | 67 | 5 (7.4%) | 5 (7.4%) | 12 (17.9%) | 9 (13.4%) |
Discussion
Ptotic patients undergoing mastectomy can be challenging to reconstruct. Wise and vertical patterns can be used to manage excess skin and final shape.1,6,17 These patterns, originally developed for mastopexy, can produce better aesthetic results in skin sparing mastectomy by reducing excess skin and avoiding scars in the superior half of the breast tissue. 1 Additionally, these approaches have the benefit of limiting scars to locations concealed by most clothing and providing vascularized dermis covering the implant. 5 This is particularly beneficial in pre-pectoral reconstruction.
The Wise pattern has been linked to significant risk of post-operative wound healing complications, particularly at the T-point.11 Another study on Wise pattern for skin sparing mastectomy had a 23.5% wound healing complication rate at the T-point, but these wounds were amenable to healing by local wound care without the need of added skin graft. 1 Further studies have also confirmed the challenges of wound healing with this technique.1,4,6 Larger breast size and perioperative axillary clearance have been associated with an increased risk of post-operative complications for Wise pattern incisions. 18 A two-staged tissue expander approach is associated with fewer complications than direct-to-implant placement following Wise pattern skin sparing mastectomy.19–21 Our study demonstrated similar cases in each group with tissue expander versus direct implant placement. The autoderm layer as a vascularized flap may help decrease complications associated with the procedure. 22 In our study, all cases included the addition of this de-epithelialized dermal flap.
There are limitations to our study. The sample size was small, although it is comparable to many previous reports on the Wise or vertical patterns. However, there is a subset of thin, ptotic patients which may benefit from Wise or vertical pattern skin reducing mastectomy. These patients may have thinner subcutaneous adipose and, hence, thinner mastectomy skin flaps. A vertical skin reducing approach may be beneficial in these patients as well by avoiding the T-point and reducing the number of incisions, which may increase dermal blood flow to the mastectomy skin flap. 17
Although the patients do not require “expansion” of skin as they are ptotic, our preference is typically tissue expander reconstruction as the vast majority of the patients have the device placed in the prepectoral plane. As such, these patients usually benefit from fat grafting to the upper pole secondarily and direct to implant is seldom “single stage reconstruction” in this patient population. As most patients will receive a second stage, tissue expander reconstruction with a partially inflated expander is therefore preferentially performed to decrease complication rate in these high risk, primarily obese patients.
The rate of infection and wound complications were high, although consistent with the literature on skin reducing mastectomy.8,10,20,22,23 The high frequency of obesity (>70%) likely influences these outcomes. Patients with lower BMIs are less likely to have excess skin and require skin reducing types of mastectomies. Our modification of the vertical pattern utilizes the excess skin as a laterally based dermal flap which can be used under the inferior part of the incision. The vertical skin reducing mastectomy technique may be a useful, simpler approach to the ptotic patient undergoing mastectomy.
Footnotes
Author Contributions: Holohan- data collection, writing; Diaz- data collection, writing; Newsom- generating figures, editing; Smith- data collection, writing; Imeokparia- data generation, writing, editing; Fisher- data generation, writing, editing, concept design; Ludwig- data generation, writing, editing, concept design; Lester- data generation, writing editing, concept design; Hassanein- concept design, writing, data generation, figure creation, editing
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
IRB Approval: Indiana University IRB #1708863832
Informed Consent: Waived by IRB (Research Ethics Board)
No Identifying information is included in images
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was waived from all patients for being included in the study.
ORCID iDs: Alex Smith https://orcid.org/0000-0003-1551-6475
Aladdin H. Hassanein https://orcid.org/0000-0002-0966-7851
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