Aesthetic design of skin-sparing mastectomy incisions for immediate autologous tissue breast reconstruction in asian women

Abstract

Background: The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer.

Methods: We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision.

Results: 281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction.

Conclusions: Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.

Keywords: Asia; Breast; Esthetics; Mammaplasty; Mastectomy.

Fig. 1

Breast reconstruction after mastectomy with an elliptical incision Breast reconstruction following mastectomy performed with a traditional elliptical incision in Asian women has a poor aesthetic result due to the vivid contrast between the highly pigmented nipple and the paler skin overlying the transverse rectus abdominis myocutaneous flap reconstruction as seen in this middle-aged woman. Particularly evident is the "circle-within-a-circle" effect due to the large area of flap skin after nipple reconstruction.

Fig. 2

Breast reconstruction after mastectomy with the peri-areolar incision An optimal aesthetic result is achieved by muscle-sparing free transverse rectus abdominis myocutaneous (ms-TRAM) flap reconstruction following skin-sparing mastectomy through a peri-areolar incision: (A) prereconstruction schematic, (B) postoperative view, and (C) following nipple reconstruction. The scar, which would otherwise be hyperpigmented and prominent, is hidden in the boundary of the reconstructed nipple-areolar complex (NAC). NAC reconstruction using our technique results in a pigmented area of skin, which closely resembles that of the contralateral NAC.

Fig. 3

Breast reconstruction after mastectomy with the peri-areolar and second elliptical incisions A second elliptical skin paddle allows reconstruction with a muscle-sparing free transverse rectus abdominis myocutaneous (ms-TRAM) flap following the excision of a distant biopsy scar: (A) prereconstruction schematic, (B) postoperative view, and (C) following nipple reconstruction. The outline of the nipple-areolar complex is entirely preserved, and the scar is well-hidden while the second skin paddle remains small and relatively inconspicuous.

Fig. 4

Breast reconstruction after mastectomy with the "racquet handle" incision Design of incision in patients with a radial biopsy scar and underlying tumor: (A) preoperative skin marking is designed to include the biopsy scar and is opened up in the form of a "tear drop" to allow excision of the tumor and (B) following reconstruction with a latissimus dorsi flap, the incision is closed in the form of a "racquet handle" with subsequent nipple reconstruction. The outline of the nipple-areolar complex is preserved in its entirety, and most of the scar is effectively camouflaged.

Fig. 5

Breast reconstruction after mastectomy using the peri-areolar incision with adjacent skin extension An extended peri-areolar incision used in instances where tumor involvement of the skin around the nipple-areolar complex necessitates the creation of an irregular, unsightly skin defect can still result in a satisfactory aesthetic result following reconstruction: (A) preoperative skin marking, (B) postoperative view following muscle-sparing free transverse rectus abdominis myocutaneous (ms-TRAM) flap reconstruction, and (C) following nipple reconstruction. The highly pigmented reconstructed nipple contrasts vividly with the paler skin paddle overlying the ms-TRAM flap used for reconstruction in this patient. However, reconstitution of as much of the nipple-areolar outline as possible optimizes the aesthetic result and reduces the area and extent of the flap skin encompassed by a pigmented scar at the flap-native skin boundary.

Fig. 6

Method for correction of the "circle-within-a-circle" deformity Secondary correction of the "circle-within-a-circle" deformity: (A) preoperative view, (B) postoperative view demonstrating the new nipple-areolar complex (NAC), which is able to match the size and position of the contralateral NAC optimally, and (C) intraoperative view; after the area of hypopigmented skin paddle is excised, the native skin envelope is undermined and the use of purse-string stitching in a cartwheel pattern for peri-areolar closure.