Mastectomy Incision Design to Optimize Aesthetic Outcomes in Breast Reconstruction

Abstract

Background: Choosing the optimal mastectomy incision must account for oncologic, reconstructive, and aesthetic considerations, including nipple preservation, mastectomy skin margins and potential for skin involvement, mastectomy skin perfusion and viability, mastectomy skin excess, previous breast scars, the reconstructive plan, and inconspicuous new scar placement. In the present study, we aimed to assess breast reconstruction aesthetics, as they are influenced by mastectomy incision design.

Methods: Nine commonly utilized mastectomy incision patterns were grouped into 3 categories: hidden scar, vertical scar, and transverse scar. Twenty plastic surgeons were asked to blindly grade before and after photographs of reconstructed breasts with regard to scar visibility and position and according to their influence on breast aesthetics.

Results: Statistically significant differences were observed between the study groups. Mastectomies and reconstructions performed through hidden incisions yield the most aesthetic results. Vertical scars are favorable to transverse scars. In the case of bilateral reconstructions, symmetric scar placement is paramount to optimizing aesthetic outcomes.

Conclusions: The mastectomy incision pattern significantly affects the aesthetic outcomes in breast reconstruction. Patterns borrowed from cosmetic breast surgery consistently yield highly aesthetic outcomes. Surgeons must consider oncologic factors and patient characteristics in choosing an ideal incision for each patient.

Fig. 1.

Nine commonly utilized mastectomy patterns have been identified. The patterns can be grouped into three categories: hidden scar, vertical scar, and transverse scar.

Fig. 2.

Pre- and postoperative photographs were presented in the survey, now arranged according to scar pattern as in Figure 1. Of note, two types of Wise pattern were reviewed: nipple sparing and non nipple sparing. An absent breast and an aesthetic natural breast were used as negative and positive controls to contextualize survey participant ratings.

Fig. 3.

Full torso photographs of bilateral breast reconstructions presented in the survey. A, Both breasts reconstructed via vertical incisions. C, Both breasts reconstructed via transverse incisions. B, asymmetric scar pattern in the left and right breasts.

Fig. 4.

Mastectomy incision pattern scores. The first row of numbers reports mean scores for individual mastectomy incision patterns. The second row of numbers reports mean scores for incision pattern categories. Hidden scar incisions result in highest aesthetic ratings. Vertical incisions result in superior aesthetic ratings compared to transverse incisions. The differences between all three categories are statistically significant. The third row of numbers reports mean post to preoperative score ratios for individual mastectomy patterns. Vertical scar patterns have significantly higher score ratios compared to transverse scar patterns. The fourth row of numbers reports mean post to preoperative score ratios categorized based on removal of excess mastectomy skin to mitigate breast ptosis. Aesthetic improvement can be achieved in breast reconstruction patients when preoperative ptosis is corrected. The difference between the two categories is statistically significant. *Statistically significant differences in data across a row.

Fig. 5.

Algorithm for choosing mastectomy incision patterns based on patient characteristics and surgeon’s preference. Portions of the diagram in gray boxes (geographic scar pattern and delayed breast reconstruction) are outside the scope of this study, are based on previously published descriptions, and are included here for completeness. *Author’s preference for autologous reconstruction.