Wise-pattern Split-reduction Incision to Facilitate Mastectomy and Direct-to-Implant Reconstruction for Superficial Breast Cancers

Abstract

The split reduction allows for oncoplastic breast conserving surgery using a modified Wise-pattern closure in ptotic patients with cancers in close proximity to a skin margin. Although cancers involving skin within the Wise pattern are conveniently resected during closure, cancers in close proximity to skin outside the Wise pattern require a modified closure. This modified Wise-pattern closure preserves skin near the inferior pole of the breast which is normally resected and shifts this resection superiorly over the cancer. This also shifts the final medial or lateral inframammary scar onto the visible breast mound. Although this split-reduction Wise pattern has been well described for resecting advanced cancers in patients who undergo oncoplastic breast conserving surgery, this approach has not been described in patients who require mastectomy. Here, we report on 10 consecutive patients with ptosis and advanced breast cancers that require skin resection outside the standard Wise pattern, where we used the split-reduction incision to facilitate mastectomy and direct-to-implant reconstruction.

Fig. 1.

52-year-old woman with a locally advanced right breast cancer invading the skin and nipple at 3 o’clock. Her left breast is marked with a standard Wise pattern in preparation for a nipple-sparing mastectomy with simultaneous mastopexy and DTIR. On the right, we use a split Wise-pattern reduction incision to both facilitate a clear anterior margin and correct her ptosis. Her right nipple will be immediately reconstructed with its pedicle located along the uninvolved lateral vertical limb. The shaded blackened area denotes the skin that will be resected. This skin resection zone has been shifted from its normal location in the inferomedial breast superiorly, over the cancer. The lateral vertical limb and extension to the inframammary fold are drawn in conventional fashion.

Fig. 2.

This is the patient in Figure 1 in the supine position on the operating room table. The two yellows arrows depict the “split” vertical limb, above and below the skin resection zone. The dark blue arrow is pointing to the area of the skin that will be resected over the cancer. The green arrow demonstrates the area where the nipple is created. The red arrow points to the zone of skin that is normally resected or deepithelialized in a standard Wise pattern but here is saved and instead shifted superiorly over the cancer. The light blue line demonstrates the final medial scar, which is shifted over the cancer instead of lying in the inframammary fold.

Fig. 3.

This is the patient 8 weeks postoperative demonstrating the well-healed Wise-pattern incisions. The left breast has undergone a Wise-pattern nipple-sparing mastectomy with bipedicle adipodermal mastopexy and DTIR. The right side has undergone a split Wise-pattern mastectomy and immediate nipple reconstruction with DTIR. She has excellent symmetry despite the split Wise pattern on the right and conventional Wise pattern on the left. The medial inframammary scar on the right breast is shifted superiorly over the cancer to facilitate a clear anterior margin.