**6. Nipple-sparing and skin-sparing mastectomy**

The safety of nipple-sparing mastectomy, depending on tumour location, has been adequately established for both in situ and early invasive breast cancer [28]. Careful preoperative assessment to ensure adequate clearance of the skin and nipple from the tumour site helps to ensure reasonable margins and reduce the risk of recurrence.

Skin-sparing mastectomy is a simpler option in central tumours involving the NAC (**Figure 26**). This is also the commonest approach utilised by general breast surgeons when undertaking combined procedures with their plastic surgery colleagues. The volume of skin excised and scar placement is often dictated by the plastic surgeon. Upfront sentinel node biopsy is carried out as a separate operation to accurately stage the axilla, prior to any reconstruction. If the axillary nodes are involved with metastatic cancer, patients are more likely to require postoperative radiotherapy. In this situation, plastic surgeons may decline immediate implant or autologous reconstruction such as LD or DIEP flap, due to poor aesthetic outcomes and higher reconstruction failure rates after radiotherapy [29, 30].

Nipple-sparing mastectomy with direct-to-implant reconstruction in the immediate setting is a safe option in experienced hands and avoids the need for a second procedure (**Figures 28** and **29**).

The IMF incision confers adequate access for undertaking mastectomy, axillary surgery and placement of mesh for lower pole support of the implant. Temporary sizers help to determine the optimal implant size and confirm tension-free wound closure. This is an important step as the mastectomy skin envelope should drape the implant rather than stretched across it. The mastectomy skin flap relies on the fine sub-dermal capillaries for its blood supply. This could potentially be compromised with excessively large implants and tight closure of the IMF and result in skin flap necrosis.

Gentle tissue handling, avoiding excessive forceful retraction and preserving the subcutaneous fat layer during mastectomy, are some of the essential steps in preserving the integrity of the mastectomy skin flap. Poor technique is probably the commonest cause for skin flap necrosis and is often reflective of inadequate training and failure to adhere to basic principles outlined above. The product often gets blamed for inferior outcomes in some of the online publications.

A single drain is left in the space between the skin flap and the mesh to remove the seroma following mastectomy. The drain is left in until the daily output slows down to approximately 30 ml/day. Build-up of seroma can cause additional tension along the wound edge or affect circulation of the skin flap and must be monitored carefully in the early post-operative period. Seroma formation is much lower with TIGR mesh compared to some ADM's in the author's

Oncoplastic Breast Surgery in the Treatment of Breast Cancer

http://dx.doi.org/10.5772/intechopen.77955

29

**Figure 29.** Six months after retropectoral implant reconstruction and TIGR mesh.

Careful patient selection is important and direct implant reconstruction is best avoided in smokers and high-risk candidates such as diabetics and women with raised BMI. It is essential to have a well-trained, dedicated breast care nurse who is qualified in wound care management. Educating patients about postoperative recovery and precautions about physical activities in the initial months after surgery helps ensure good cosmesis and minimises the risk of

**7. Skin-reducing mastectomy, with or without nipple preservation**

Nipple-sparing mastectomy is usually carried out via the IMF approach in small- to mediumsized breasts. It is possible to achieve nipple-sparing mastectomy in larger patients who wish to remain the similar size, via the same approach. In younger patients, some degree of skin contraction is achievable but decline in collagen levels with normal ageing process can result

Most large breasted women, however, are keen to achieve a smaller reconstructed breast volume and skin-reducing mastectomy techniques can be used with immediate implant reconstruction, with or without nipple preservation. Patients need to be cautioned about

own presented series [24].

wound-related complications.

in redundant skin flaps.

**Figure 28.** Post-neoadjuvant chemo BL nipple-sparing mastectomy.

**Figure 29.** Six months after retropectoral implant reconstruction and TIGR mesh.

Skin-sparing mastectomy is a simpler option in central tumours involving the NAC (**Figure 26**). This is also the commonest approach utilised by general breast surgeons when undertaking combined procedures with their plastic surgery colleagues. The volume of skin excised and scar placement is often dictated by the plastic surgeon. Upfront sentinel node biopsy is carried out as a separate operation to accurately stage the axilla, prior to any reconstruction. If the axillary nodes are involved with metastatic cancer, patients are more likely to require postoperative radiotherapy. In this situation, plastic surgeons may decline immediate implant or autologous reconstruction such as LD or DIEP flap, due to poor aesthetic outcomes and higher

Nipple-sparing mastectomy with direct-to-implant reconstruction in the immediate setting is a safe option in experienced hands and avoids the need for a second procedure

The IMF incision confers adequate access for undertaking mastectomy, axillary surgery and placement of mesh for lower pole support of the implant. Temporary sizers help to determine the optimal implant size and confirm tension-free wound closure. This is an important step as the mastectomy skin envelope should drape the implant rather than stretched across it. The mastectomy skin flap relies on the fine sub-dermal capillaries for its blood supply. This could potentially be compromised with excessively large implants and tight closure of the IMF and

Gentle tissue handling, avoiding excessive forceful retraction and preserving the subcutaneous fat layer during mastectomy, are some of the essential steps in preserving the integrity of the mastectomy skin flap. Poor technique is probably the commonest cause for skin flap necrosis and is often reflective of inadequate training and failure to adhere to basic principles outlined above. The product often gets blamed for inferior outcomes in some of the online publications.

reconstruction failure rates after radiotherapy [29, 30].

**Figure 28.** Post-neoadjuvant chemo BL nipple-sparing mastectomy.

(**Figures 28** and **29**).

28 Breast Cancer and Surgery

result in skin flap necrosis.

A single drain is left in the space between the skin flap and the mesh to remove the seroma following mastectomy. The drain is left in until the daily output slows down to approximately 30 ml/day. Build-up of seroma can cause additional tension along the wound edge or affect circulation of the skin flap and must be monitored carefully in the early post-operative period. Seroma formation is much lower with TIGR mesh compared to some ADM's in the author's own presented series [24].

Careful patient selection is important and direct implant reconstruction is best avoided in smokers and high-risk candidates such as diabetics and women with raised BMI. It is essential to have a well-trained, dedicated breast care nurse who is qualified in wound care management. Educating patients about postoperative recovery and precautions about physical activities in the initial months after surgery helps ensure good cosmesis and minimises the risk of wound-related complications.
