Excess Horizontal Breast Skin Facilitates a Simpler Wise Pattern Split Reduction Incision for Superficial Cancers

Summary:

The Wise pattern split reduction (WPSR) incision is useful in patients with cancers near a skin margin that lies outside of the standard pattern. Instead of resecting skin in the standard inferolateral or inferomedial sections of the breast, this modified Wise pattern preserves this skin and instead resects skin over the tumor, ensuring a clear anterior margin and shifting the scar onto the breast instead of the medial or lateral inframammary fold. This approach makes use of the excess vertical skin of the breast. We have found that in certain situations, a WPSR incision can instead rely on the excess horizontal skin of the breast (the skin between the preoperatively drawn medial and lateral vertical limbs). This modification is useful for superficial, smaller, less extensive cancers that lie just medial or lateral to the preoperative Wise pattern vertical limb markings, resulting in a smaller final scar and a less extensive and complex surgical procedure. Patients with breast cancer were recruited into this study retrospectively after either a preoperative or intraoperative decision was made to use a WPSR incision using horizontal skin excess. This report summarized our experience with 10 consecutive patients who successfully underwent this approach to facilitate a clear anterior margin.

Takeaways

Question: How can we more simply modify the Wise pattern to remove cancers that are close to the skin that we typically save when we are using this incision?

Findings: Here, we use the horizontal skin excess or the excess width of the breast to replace the skin that requires removal because of its proximity to the cancer.

Meaning: This study demonstrates that instead of using the vertical excess skin of the breast to modify the Wise pattern to remove superficial breast cancers, using the horizontal excess is a simpler approach typically resulting in a smaller and less noticeable scar on the visible surface of the breast.

INTRODUCTION

The Wise pattern is a useful incision for reshaping the breast in ptotic patients undergoing breast-conserving surgery (BCS)¹ or mastectomy.² Although cancers within the Wise pattern are easily resected, superficial cancers outside the Wise pattern often require a modified closure to ensure a negative anterior margin. The Wise pattern split reduction (WPSR) incision uses excess vertical breast skin and shifts the resection pattern onto the breast mound instead of resecting inferomedial or inferolateral skin.^3–6 This typically involves a large scar over the anterior breast and facilitates resection of a broad expanse of skin, useful for larger cancers. Ptotic breasts also have excess horizontal skin, which can be used to ensure a clear anterior margin for superficial cancers. This strategy preserves the skin between the vertical limbs, which replaces the skin outside the Wise pattern that has been removed with the specimen (Fig. 1). This horizontal skin excess is typically less extensive than the vertical excess and useful for smaller cancers in close proximity to the breast meridian. Here, we report on 10 patients undergoing mastectomy or BCS for superficial breast cancers located outside the standard Wise pattern where excess horizontal breast skin was used to design a WPSR incision to ensure a clear anterior margin.

Fig. 1.

This patient has an upper outer quadrant right breast cancer that is in proximity to the skin. Horizontal skin excess, located above the nipple–areola complex, based off the medial vertical limb can immediately replace this skin deficit.

METHODS

The author conducted a retrospective case and chart review of ten consecutive patients undergoing a WPSR using horizontal skin excess in his surgical practice with a minimum of 6 months follow-up. We excluded patients who were actively smoking or had uncontrolled diabetes, and patients whose skin excess required skin replacement involving the nipple–areolar complex. Demographics, intraoperative details, follow-up and complications were recorded.

Patients undergoing Wise pattern BCS or mastectomy were marked in the standing position and then placed supine where the author used an 8 to 12 MHz linear array ultrasound to determine the area of skin outside the Wise pattern deemed unsafe to preserve. In the supine position, markings were drawn for excising skin in continuity with the medial or lateral vertical limb while preserving a mirror image skin pattern, in continuity with the preserved vertical limb, for replacement (Fig. 1). The skin excision could assume any shape or size as long as there was sufficient excess horizontal skin for replacement (Figs. 2, 3).

Fig. 2.

This patient had a central breast cancer that required removal of her nipple (it was immediately reconstructed) and resection of lateral breast skin. We used excess horizontal skin, located below the nipple–areola complex (which was resected and reconstructed), based off the medial vertical limb to immediately replace this skin. The final scar is shifted lateral to the breast meridian because excess horizontal skin based off the medial vertical limb is placed into this deficit.

Fig. 3.

This patient was referred after an attempt at breast conservation demonstrating multiple involved margins. To reconstruct her breast using the Wise pattern after clearing her margins, we used the horizontal excess based off the lateral vertical limb to compensate for the deficiency of skin she had medially (secondary to the location of the initial incision in the far medial breast).

RESULTS

Patients’ ages and body mass indexes ranged from 31 to 81 years (mean = 52.4 y, SD = 9.8) and 22.1 to 41.2 kg/m² (mean = 31.6 kg/m², SD = 47), respectively. Patients underwent Wise pattern BCS (8 of 10, 80%) or mastectomy (2 of 10, 20%) and immediate implant reconstruction. Tumor sizes ranged from 1.1 to 4.1 cm (mean = 2.9, SD=0.7) and partial mastectomy specimen weights ranged from 29 to 210 g (mean = 78.4 g, SD = 25.2). The 2 mastectomy specimen weights were 515 and 635 g. The distance between the tumor and anterior skin margin ranged from 0 to 0.4 cm (mean = 0.15 cm, SD = 0.07) on preoperative imaging. The width (base) and height of the skin island removed ranged from 2 to 6 cm (mean = 4.2 cm, SD = 1.7) and from 3 to 8 (mean = 4.4, SD = 2.0). Seven (70%) patients used excess skin in continuity with the medial vertical limb (cancers ranging from 3 to 7 cm [mean = 5.0 cm, SD = 1.3] from the preoperatively drawn lateral vertical limb), whereas the remainder used excess skin in continuity with the lateral vertical limb (cancers ranging from 2 to 5 cm [mean = 3.7 cm, SD = 1.2] from the preoperatively drawn lateral vertical limb) to replace resected skin. Tumor sizes ranged from 1.2 to 3.9 cm (mean = 2.4 cm, SD = 1.1). There were 7, 2, and 1 patients where we used inferior, medial, and lateral pedicles, respectively. One patient required a re-excision of her margins, which was successful. Follow-up ranged from 6 to 36 months (mean = 9.6 mo, SD = 5.7). No patient required revisional surgery. Two (20%) patients had wound dehiscence (both undergoing BCS) at the inframammary fold and healed within eight weeks of surgery. There were no instances of skin necrosis or wound dehiscence related to WPSR incision.

DISCUSSION

The Wise pattern is useful to reshape the breast for BCS or optimize the skin envelope for postmastectomy reconstruction^1,2 but does not consider the proximity of the cancer to the skin envelope. When a patient presents with a cancer located outside the Wise pattern in proximity to the skin that cannot be preserved, oncological considerations must supersede aesthetic concerns, and the Wise pattern vertical limb must be “split” which allows for excision of skin over the cancer, placing a scar on the anterior breast mound. Although this is not aesthetically ideal, it allows for wide clearance of the cancer.

Previous descriptions of the WPSR by Silverstein et al,³ Santanelli et al,^4,5 and Schwartz⁶ used the vertical breast skin excess for BCS or mastectomy, preserving either the inferomedial or inferolateral breast skin, shifting the excision instead over the cancer, placing the scar on the anterior medial or lateral surface of the breast. For larger cancers, this is an excellent option, as there is often significant vertical skin excess in ptotic breasts allowing for a large expanse of skin to be excised and replaced. This approach, however, places a large incision over the anterior breast, which is clearly visible and often unnecessary for smaller, superficial cancers in proximity to the preoperatively drawn vertical limbs. In these patients, there is often sufficient excess skin between the vertical limbs to immediately replace this skin, resulting in minimal additional scarring, while still aggressively resecting the cancer. Our results here confirm that using horizontal excess breast skin can safely facilitate a WPSR in appropriately selected patients.

Limitations of this study include the lack of any blinded objective assessment of postoperative aesthetic outcomes and small study population. This approach also has minimal utility in patients who have extensive skin involvement and a limited amount of horizontal skin excess, especially if the tumor is located far from the breast meridian. This approach is also not useful in patients where the nipple–areolar complex comprises part of the horizontal skin excess needed for skin replacement.

DISCLOSURE

The author has no financial interest to declare in relation to the content of this article.