**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 in redundant skin flaps.

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 a higher than average risk of nipple necrosis with complex surgery. A skin reducing wisepattern mastectomy using bi-pedicle dermal flap to maintain vascular integrity of the NAC is described by the author and recently accepted for publication (**Figures 30** and **31**). This technique is a variation of the previously published modified Letterman technique [31] and early results of the author's series were presented as poster at the Leura 8 Conference in Sydney 2016.

This technique can be used in large breasted women for immediate implant-based and autologous reconstruction. It is also possible to use this technique for revision surgery to address any redundant skin flap after previous implant reconstruction. The bi-pedicle dermal flap provides variable length for adjusting the nipple height to the desired position based on the final breast volume and maintains dual vascular supply to the NAC. The dermal flap also protects the incision site from the underlying implant and mesh and minimises risk of implant infection or reconstruction failure.

Tension-free closure of the wound helps reduce pressure on the skin flap and NAC from the underlying implant and protects the fine sub-dermal capillaries supplying the skin flap following mastectomy (**Figure 32**). Use of drains to anticipate any seroma formation and postoperative swelling also helps mitigate the additional risk at the suture line and viability of the NAC.

**Figure 31.** Wise pattern skin-reducing nipple-sparing mastectomy using bi-pedicle dermal flap and implant reconstruction

Oncoplastic Breast Surgery in the Treatment of Breast Cancer

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

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with TIGR mesh.

**Figure 32.** Viable NAC at time of skin closure.

*Goldilocks mastectomy* with implant reconstruction, using a wise-pattern skin incision and dermal flap for lower pole support has been previously described. The nipple vasculature is maintained on the superior pedicle only and is best avoided in older patients or high-risk women such as smokers, diabetics and raised BMI [32].

**Figure 30.** Pre-operative skin-reducing mastectomy.

Oncoplastic Breast Surgery in the Treatment of Breast Cancer http://dx.doi.org/10.5772/intechopen.77955 31

**Figure 31.** Wise pattern skin-reducing nipple-sparing mastectomy using bi-pedicle dermal flap and implant reconstruction with TIGR mesh.

**Figure 32.** Viable NAC at time of skin closure.

a higher than average risk of nipple necrosis with complex surgery. A skin reducing wisepattern mastectomy using bi-pedicle dermal flap to maintain vascular integrity of the NAC is described by the author and recently accepted for publication (**Figures 30** and **31**). This technique is a variation of the previously published modified Letterman technique [31] and early results of the author's series were presented as poster at the Leura 8 Conference in

This technique can be used in large breasted women for immediate implant-based and autologous reconstruction. It is also possible to use this technique for revision surgery to address any redundant skin flap after previous implant reconstruction. The bi-pedicle dermal flap provides variable length for adjusting the nipple height to the desired position based on the final breast volume and maintains dual vascular supply to the NAC. The dermal flap also protects the incision site from the underlying implant and mesh and minimises risk of implant

Tension-free closure of the wound helps reduce pressure on the skin flap and NAC from the underlying implant and protects the fine sub-dermal capillaries supplying the skin flap following mastectomy (**Figure 32**). Use of drains to anticipate any seroma formation and postoperative swelling also helps mitigate the additional risk at the suture line and viability of the

*Goldilocks mastectomy* with implant reconstruction, using a wise-pattern skin incision and dermal flap for lower pole support has been previously described. The nipple vasculature is maintained on the superior pedicle only and is best avoided in older patients or high-risk

Sydney 2016.

30 Breast Cancer and Surgery

NAC.

infection or reconstruction failure.

women such as smokers, diabetics and raised BMI [32].

**Figure 30.** Pre-operative skin-reducing mastectomy.
