A multidisciplinary view of mastectomy and breast reconstruction: Understanding the challenges

Abstract

The current review paper was written in collaboration with breast cancer surgeons from the European Breast Cancer Research Association of Surgical Trialists (EUBREAST), a breast pathologist from the Danish Breast Cancer Group (DBCG), and representatives from the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer course. Herein we summarize the different mastectomies and reconstruction procedures and define high-risk anatomical areas for breast cancer recurrences, to further specify the challenges in the surgical procedure, histopathological evaluation, and target volumes in case of postmastectomy irradiation, as recommended by the ESTRO guidelines according to the surgical procedure. The paper has original figures and illustrations for all disciplines for in-depth understanding of the differences between the procedures.

Keywords: Breast cancer; Mastectomy; Nipple sparing; Radiation; Reconstruction; Skin sparing.

Fig. 1

The 3-dimensional superficial fascia system of the mammary gland. Camper’s and Scarpa’s fascia are a thick superficial and deep layer, respectively, of the anterior abdominal wall.

Fig. 2

A patient who underwent Halsted’s mastectomy on the left side and modified radical mastectomy on the right. On the left, deformity from pectoral muscle removal is noted and the ribs are easily seen. The arrow on the left shows a local recurrence at the mastectomy scar, 25 years after the surgical procedure. On the right side, excess skin is noted.

Fig. 3

A-D: Mastectomy incision according to tumour location.

Fig. 4

Excessive tissue causing wrinkling at the edge of a scar as a result of residual subcutaneous fat from the chest wall (Dog ears).

Fig. 5

A, B: (A) Bilateral Skin sparing mastectomy (SSM) with (B) nipple reconstruction, all is native skin breast. The SSM was done via horizontal elliptical skin incision, which allows for a 360° freedom to resect the breast parenchyma, at all locations. It also allows full access to the axilla.

Fig. 6

Nipple sparing mastectomy in a peri-areolar approach.

Fig. 7

Nipple-sparing mastectomy (NSM) with a peri-areolar incision over 180°, with a radial elongation (a hockey-stick incision). It allows a direct access to the retro-areolar space and even to the medial quadrants.

Fig. 8

Anterior plane of dissection in skin sparing and nipple sparing mastectomy, showing the subcutaneous fat. The thickness of the subcutaneous fat depends on the body mass index, but also varies according to different locations of the breast. The observation that there is a tendency to a thinner layer at the lower pole, assumed to be because of the weight of the mammary gland, explains, along with the gravitation force on the implant, why this area is more difficult to maintain the viability of the skin. Thus, the use of supportive material (such as a mesh) may be required to reducing the pressure.

Fig. 9

Microscopic view of the anterior resection margins of skin/nipple sparing mastectomy.

Fig. 10

Posterior resection border, the breast glandular tissue resected including the pectoralis major fascia. The figure shows the delicate fascia encapsulating the glandular tissue at the posterior plane and the perforating vessels.

Fig. 11

A,B: The use of supportive mesh to complete the pectoralis muscle deficit at the lower pole and create a pocket to hold the subpectoral implant.

Fig. 12

Skin sparing mastectomy with skin reducing procedure for mastopexy, using an inverted T incision, with preserving of autologous de-epithelialized dermal graft on the lower pole, to serve as a dermal sling. Immediate reconstruction was done using anatomical shaped silicone implant, 610 cc, placed posterior to the pectoral major muscle (sub-pectoral) which is covering the cranial pole of the implant. The infero-lateral pole is covered by partly absorbable synthetic mesh, and on top of the mesh the dermal sling. All is then covered by the native-breast skin flap adjusted from the medial and lateral sides, with a visible scar in the form of inverted “T”.