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Skin Sparing Mastectomy

Skin sparing mastectomy is surgery that removes the tumor and surrounding breast tissue, the nipple, areola, and the original biopsy scar, but leaves the breast skin. This creates a skin envelope for breast reconstruction. This approach is only used when immediate breast reconstruction is planned. It may not be suitable for some large tumors or tumors that are close to the surface of the skin.  Although skin sparing mastectomy is ideal surgery for a good cosmetic outcome, there are a few things you must consider.

 In a skin sparing mastectomy the tumor must be far enough away from the skin for your surgeon to confidently remove all cancer cells. Another factor is that the cancer cells must be far enough away from the nipple and ducts so all cancer cells can be removed. Often, this is  something that some surgeons are more confident performing than others. It is important that you ask your surgeon what techniques they are trained in and what techniques they are confident in applying to your case. If you are unsatisfied with the response, it is your right to go for a second opinion. However, many cancer cases are time sensitive and require immediate action.

Implant-based reconstruction is the most common method of breast reconstruction and flap based reconstruction is the second most common method used. Each breast reconstruction method has advantages and disadvantages.
Advantages of immediate reconstruction include: increased psychosocial well being; improved body image; improved sexual function; and patients may have a better cosmetic result because the skin envelope is preserved providing a similar shape as your natural breast. Disadvantages of immediate reconstruction include: a potential for delaying necessary chemotherapy due to complications of the reconstruction; radiation may affect the cosmetic result; some immediate reconstruction results in several nips and tucks; and there is an increased possibility of complications by combining two procedures into one procedure.

Immediate reconstruction procedures involve:

Expander to implant: a tissue expander is placed under some of the pectoral muscle at time of mastectomy, the expander is gradually filled with saline over several weeks stretching the skin and muscle to create a pocket for the permanent implant. In a second surgery, the expander is removed and the permanent implant is placed under the pectoral muscle. The expander may also be used to retain a skin envelope through any postmastectomy radiation therapy, since radiation often distorts the skin and can damage an implant or tissue flap. To achieve the best cosmetic result, some surgeons will recommend a 2 staged approach, however, some surgeons may be very comfortable with placing the final implant immediately.

Direct to final implant: this option requires a surgeon comfortable with the final placement of the implant at the mastectomy surgery and generally only a select group of candidates are offered this option. A direct to implant reconstruction is well suited for women interested in downsizing their final breast size. Downsizing the final breast size can avoid undue tension on the mastectomy skin that increasing the breast size may cause. Too much tension on the mastectomy incision may cause complications such as a wound opening and exposure of the implant, requiring implant removal and additional surgery. Acellular dermal matrix may offer some surgeons a solution to minimize any risk of wound opening. Acellular dermal matrix assimilates quickly in the body and provides an extra layer of tissue to act as a supportive sling to aid positioning of the implant.

Direct to final implant with lat flap: the latissimus dorsi muscle is located on the back side of the body and can offer an alternative to acellular dermal matrix as a support for the implant. In a lat flap procedure a muscle from the back (latissimus doors), with connected skin, fat, and blood vessels, are passed through a tunnel under the skin to the chest to help form a new breast or to shape the pocket for a breast implant. The transferred tissue remains attached to its original blood supply making the lat flap procedure less complicated than other flap procedures. Once the lat flap is brought from the back to the chest, it is stitched to the pectoral muscle to support the implant. The lat flap can also be used with an expander in a 2 step expander reconstruction procedure.

Advantages of lat flap: can act like acellular dermal matrix to protect the implant in immediate reconstruction; vessels remain connected so no reattachment is required, lessening the potential for vessel failure; no microsurgery is required, so less risk of flap failure; shorter procedure and hospital stay compared to other flaps.
Disadvantages of lat flap: scarring on the back; loss of lat muscle function (not significant but some patients notice when performing extreme activity such as rock climbing).

This type of reconstruction best fits a patient who: in immediate setting must be a candidate for skin sparing; insufficient tissue for other flaps but would like to have a one stage reconstruction direct to implant bypassing the expander stage; would like to avoid abdominal surgery.

Implant to flap: if an implant is placed at time of mastectomy and any complication occurs with this implant, this may require removal of the implant, at which point a flap reconstruction may be the only available option to rebuild the breast area.
Implant to implant: an implant can be rejected by the body either by implant exposure or infection. The implant may need to be removed and possibly replaced. If the implant is immediately replaced, there is a potentially higher risk of reinfection or implant exposure. After implant exposure, it is best to consider removal of the compromised implant and then plan for another reconstruction at a later date with a flap procedure or possibly re-expansion for an implant.
Direct to flap: some patients will prefer to use their own tissue rather than an implant for reconstruction. This may be the best option if there has been any past radiation to the chest, since radiated skin is often difficult to stretch. If radiation is needed it may be aesthetically beneficial to delay a flap reconstruction to minimize any tissue damage that could be caused by radiation.
Expander to flap: an expander is placed at time of mastectomy. this approach is used when a flap reconstruction is planned for a later date.

Implant-Based Advantages: less surgical time and recovery time; fewer scars; satisfactory shape in clothing.
Implant-Based Disadvantages: many clinic appointments during the expansion process; two surgical procedures (tissue expander placement and implant placement); potential problems with implant including infection may require more surgery (this is rare, less than 5% and most will respond to antibiotics); often difficult to achieve appearance of a natural breast; visual or physical distortions such as capsular contracture, rippling or bursting; extremely thin skin may show the guideline features of the implants (used by surgeons for placement) and possibly pain are fairly common in patients undergoing reconstruction with implants; implants may need to be replaced periodically although most implants will last a lifetime.

Implant-Based Reconstruction best fits a patient: no history of previous radiation to the breast or chest wall or will not need radiation as part of the treatment plan; does not have enough fatty tissue in stomach area for flap options; no desire for a tissue flap operation; has a good skin pocket/envelope for implant; minimal compromised tissue at the mastectomy site; prefers shorter surgical time and recovery times; wants a more perky (augmented) looking reconstruction.

Mastopexy is a procedure that can be completed at the same time as any breast surgery. In a mastopexy procedure, your surgeon will lift or reduce the opposing breast in order to create symmetry with the reconstructed breast.

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