The 2003 Annual Meeting of OASYS_NEW

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Skin-Sparing Mastectomy and Autogenous Microsurgical Breast Reconstruction in an Asian Population - the Influence of Biopsy Scar Location and Skin Preservation on Aesthetic Outcomes

Sng KW1, Tan BK1, Hong SW1, Wee SB2, Ang BK3, Chew W4, and Tan KC1. (1) Department of Plastic Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore, (2) National Cancer Centre, Outram Road, Singapore, Singapore, (3) Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore, (4) Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore

Introduction: Results of skin-sparing mastectomy (SSM) breast reconstruction are superior because of preservation of the breast skin envelope. The breast biopsy scar location can hinder preservation of breast skin.

Patients and Methods: 41 cases of SSM and reconstruction over 2.5 years were assessed. We identified the location of biopsy scars and correlated these with incisions used for mastectomy, and hence amount of skin preserved.

Reconstruction was by autogenous tissue; 88% involved free tissue transfer.

Flap

Free/Pedicled

Number

TRAM

Free

32

DIEP

Free

4

LD

Pedicled

2

TRAM

Pedicled

3
   

41

Aesthetic outcomes were analyzed with regards to breast shape and symmetry, areola positioning and visibility of scars.

Results:

Patients were divided into 3 groups:
Group Mastectomy Extent of breast skin excision Number
1 Complete SSM Only nipple-areola complex (NAC) 20
2 Partial SSM NAC + surrounding skin containing scar 14
3 Near- complete SSM NAC and scar excised through separate incisions, preserving intervening bridge of skin

2nd defect reconstructed with 2nd skin paddle

 5
3 Near-complete SSM NAC and radially positioned scar excised through teardrop incision

The triangular tail can be closed during nipple reconstruction to give a linear scar

 2

There was 1 partial flap loss because of fat necrosis. Donor site problems were minimal: 1 haematoma and 1 abdominal hernia.

Group 1 (complete SSM) had superior aesthetic results – skin preservation gave good shape and symmetry, and after nipple-areola reconstruction, the breast was virtually scarless. In group 2 (partial SSM), the neo-NAC was surrounded by a circular rim of donor skin, creating a "circle-within-a-circle" appearance. The modified approaches in group 3 helped to maximize skin preservation, minimize scars, and retain the anatomic position of the areola.

Discussion:

From an aesthetic viewpoint, the breast can be divided into 3 zones:

  1. Zone 1: within the NAC

  2. Zone 2: >3.5 cm from edge of NAC

  3. Zone 3: <3.5 cm from edge of NAC

Biopsy scars should be confined to Zone 1. Mastectomy can then be performed through a circumareolar incision, allowing maximal preservation of breast skin. This is especially so in the Asian breast, which is smaller, and more amenable to complete SSM.

Scars situated in Zone 2 can be excised using a separate elliptical incision to conserve skin.

Scars in Zone 3 should be avoided where possible. If biopsy is performed on a suspicious lesion in this zone, a radially positioned scar is recommended.


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