Skin-Sparing Total Mastectomy

Abstract

Skin-sparing mastectomy is done if oncologically feasible and when mastectomy is followed by immediate reconstruction. This chapter lists the indications, essential steps, common technical variations, and complications of the procedure. A detailed template operative dictation note is included.

Indications

• Ductal carcinoma in situ (DCIS) not amenable to breast conservation or patient requesting mastectomy, to be followed with reconstruction

• Breast cancer treatment in selected patients, to be followed with reconstruction

• Prophylaxis of carcinoma in select high-risk patients, to be followed with reconstruction

Essential Steps

• 1. Confirm side of surgery.

• 2. Sentinel lymph node (SLN) biopsy if indicated for staging of the axilla.

• 3. Circumareolar skin incision or incision tailored to geometry of tumor.

• 4. Develop skin flaps.

• 5. Dissect breast from chest wall.

• 6. Hemostasis.

• 7. Orient specimen for pathology.

• 8. Irrigate and pack wounds for hemostasis prior to reconstruction.

Note These Variations

• SLN biopsy if patient has invasive or noninvasive carcinoma.

• Incision is tailored to allow maximum skin salvage but to excise scar from previous biopsy (if needed).

• Prophylactic mastectomy is commonly bilateral.

• Nipple-sparing mastectomy being offered in some centers.

Complications

• Skin necrosis

• Wound infection

• Seroma

Template Operative Dictation

Preoperative Diagnosis

Invasive carcinoma/dcis/prophylaxis of the left/right/bilateral breast(s)

Procedure

Left/right/bilateral skin-sparing mastectomy

Postoperative Diagnosis

Same

Indications

If DCIS/invasive carcinoma: This ___-year-old female with a left/right breast mass/abnormality on mammogram that on workup with fine-needle aspiration/biopsy was found to be ductal carcinoma in situ/invasive carcinoma. If prophylactic: This ___-year-old female was known to be at significantly high risk of breast cancer due to BRCA1/BRCA2 mutation/other. After discussion of options, the patient requested simple mastectomy with immediate reconstruction.

Description of the Procedure

After identifying the patient and verifying the operative site, the patient was brought into the operating room. Time-outs were performed using both preinduction and pre-incision safety checklists to verify correct patient, procedure, site, and additional critical information prior to beginning the procedure. General anesthesia was induced. All pressure points were appropriately padded. The left/right/bilateral breast(s) and axilla was/were then prepped and draped in the usual sterile fashion.

If sentinel lymph node biopsy was performed, include details.

A left/right circumareolar/____ skin incision was made. Skin flaps were developed in the avascular plane using blunt and sharp dissection with scissors/electrocautery superiorly to the clavicle, inferiorly to the inframammary skin fold, laterally to the latissimus dorsi, and medially to the sternal border. The breast was then removed from the chest wall using electrocautery, leaving/not leaving the pectoral fascia. Perforating branches of the internal mammary vessels were/were not spared. Hemostasis was obtained with electrocautery. The specimen was oriented and submitted whole to Pathology. The wound was irrigated with sterile saline and packed. The identical procedure was performed on the right/left side. The operation was then passed on to plastic surgery for immediate reconstruction.