199 8 Prophylactic Subcutaneous Mastectomy Subcutaneousmastectomy is definedasthe complete removal of operation or by mastectomy. Lobularcarcinoma in situ— once all breast tissuewhile leavingthe nipple– areola complex intact. considered aclassic indicationfor subcutaneous mastectomy — is Dissectiononthe glandleaves more breast tissue than strict no longerviewedasnecessarily precancerous, andtreatment subcutaneousdissection (removal of 90 %vs. 95– 98 %). In our thus consists of clinical observationwithout immediate surgical view,removal of the nipple– areolacomplexinprophylactic sur- implications.Surgeryisalsonolongerindicatedfor atypical gery is notjustified, sinceth eresulting aestheticcompromise intraductal or lobularhyperplasias, which were previously outweighsany gain in oncological safety. viewed as precancerous lesions. Theintroductionofsilicone gelimplants in the 1960sand Surgicaltreatment of theveryrarecases of diffusepapilloma- early 1970 shelpedpopularize the notion of complete removal tosis (with or without atypia) should be discussedwith the of all vulnerable breast tissue, followedbyimplant reconstruc- patientonthe basis of theindividualcase. tion.Widespread useofthe techniquewas basedonthe belief Ultimately,itisthe patient ’ spersonal decisionwhether sub- that theresultingbreast had anatural appearance andfeel. Over cutaneous mastectomy is appropriate. Allthe potential draw- time,however,itbecame evidentthat inadequate soft-tissue backsofthissurgicalprocedure have to be clearlyexplained coverageofthe implant could lead to majorsurgicalcomplica- andthoroughlydiscussed. tions — resultinginpoor or even disastrous cosmeticoutcomes, Factors thatargue in favor of subcutaneousmastectomy in with theassociatedpsychological distress. individual patients range from psychologicaldistressinpatients Thegoalofthe operationasoriginally defined— removing as withcancerphobia to detection of a BRCA1 or BRCA2 gene much at-risk tissue as possible, while at thesame time recogniz- mutation. Afamily historyofbreast cancer canalso be an in- ingthe aestheticand psychosexualimportanceofthe breast— dicationfor prophylactic mastectomy,particularly if thetissue also provedunattainable. Resectionleadstoimpairedsensation concernedisdiffi cult to examineusing routinesurveillance pro- in thebreast skin and complete denervation of the nipple.Sub- cedures. In the United States, prophylactic mastectomyisoften sequentimplant reconstruction ofteninvolves complicatio ns considered to be indicatedinpatients whohavecancerinthe such as capsularcontracture, aforeign-bodysensation, coldness, contralateral breast. anddisplacement,and thecorrespondinglossofnatural appear- ance. Subcutaneous mastectomies aretherefore beingcarried out less and less often. Surgical Technique However,the value of this technique wasconfirmedinastudy by Hartmann (1999), whoconfirmedthatthe risk of developing It should be mentionedinitially that there is no surgical standard cancerdeclinesindirectproportiontothe amount of breast of care forsubcutaneous mastectomy.Generally speaking,sur- tissueremoved— which in clinical termsislogical. In high-risk gery onlymakessense in conjunctionwithreconstruction. This patients, the likelihood of developing breast cancercouldthusbe increases thedegree of variation, however,since the choiceof reducedby90%by prophylactic mastectomy. This possibility had reconstruction can also influence thetype of resection. long been viewed skeptically,and the study confirmedthe onco- Some surgeons carryout subcutaneous mastectomy in the logical effectiveness of subcutaneousmastectomy. same way as amodifiedradical mastectomy.Alongtransverse In view of theincreasingincidence of breast cancer andthe incisionismadeacross thebreast, forwidesurgical exposure, identification of gene mutations that canleadtoit, theissue of andthe nipple – areola complexisresected. In our opinion, this preventive mastectomyiscurrently beingreassessed. In addition, procedure should no longer be used. Instead,aesthetic factors thedevelopmentofautologoustissue reconstruction hasbeena should also be givendue consideration in prophylactic surgery, as major step forward in avoiding thecomplications associatedwith they can help minimize physical andpsychologicaldamage. implants. Some surgeons prefer to dissect athickerflap of skin and glandular tissue (particularly in combinationwith implant recon- struction). However,thisreduces theeffectiveness of theproce- Indications dure. Dissectiononthe glandular tissue achieves a90%reduction of breast tissue.Extensivesubcutaneousmastectomy,using strict From thephysician’ spoint of view,there is no medical reason for subcutaneous dissectionsimilar to atotal mastectomy,removes performingsubcutaneous mastectomy.Malignant changesorin- 95– 98 %ofbreast tissue. traductalatypia have to be managedwithabreast-conserving aus: Gabka u.a., Plastic and Reconstructive Surgery of the Breast (ISBN 9783131035721) 2009 Georg Thieme Verlag KG 206 8ProphylacticSubcutaneous Mastectomy a b d c Fig. 8.5a– d The skin reductiontechniqueinsubcutaneousmastectomy. c Themedial andinferior wound margins arejoinedafter thenipplehas been a, b The vertically and inferolaterallypedicledflapis exposedand theperiareolar suturedintoposition. region is de-epithelialized. Thecorners that aretobeunited aremarked. To d Afterthe wound margins have been joined. facilitate transposition of thenipple, theinferior p eriareolar dermal layerisincised, while thelateraldermal layer is sparedtosupplynourishment. aus: Gabka u.a., Plastic and Reconstructive Surgery of the Breast (ISBN 9783131035721) 2009 Georg Thieme Verlag KG AutologousTissueReconstructi on 207 a b c d Fig. 8.6a– d Intraoperativeillustrationsofskinreduction mammaplastywith c Afterde-epithelialization, thedermal layeristransected2cm belowthe corners simultaneoussubcutaneousmastectomy. of the superiorly pedicled flap. Thelowerdermallayer is used foradditional a Theincision lines have been marked. protection of the implants aftersubmuscular placement. b Theentiregland, includingthe Cooper ligaments, is resected from the d Followingsubmuscular placementofthe implant,the nipple is moved subcutaneoustissue; thenippleishollowed outand athinlayer of dermal fat superiorly aftertransection of the uppercorners. remains. aus: Gabka u.a., Plastic and Reconstructive Surgery of the Breast (ISBN 9783131035721) 2009 Georg Thieme Verlag KG 211 9 Modified Radical Mastectomy Indications extend into the cleavage area. Ultimately, the primary concern is local tumor control. Breast-conserving surgery is now regarded throughout the world Grasping the superior and inferior skin flaps with ring forceps as being the standard procedure for the treatment of breast facilitates subcutaneous dissection of the gland by keeping the cancer. However, if it is contraindicated, or if the patient so skin taut. Care should be taken to remove all of the glandular wishes, a modified radical mastectomy has to be performed. A tissue from the subcutaneous tissue. The technically challenging modified mastectomy rate of 30 % can be expected. steps are subcutaneous dissection and exposure of the borders of The indications for modified radical mastectomy include fac- the gland. Dissection of the glandular tissue off the pectoralis tors related to tumor biology, such as multicentric growth, ex- muscle and resection of the pectoralis fascia (following the tensive ductal carcinoma in situ, and signs of inflammation. A course of the lymphatic vessels) is technically easier, as it con- modified radical mastectomy may also be indicated if there is an stitutes an anatomically well-defined layer. unfavorable relation between breast and tumor size. Finally, the Subcutaneous dissection of glandular tissue continues into the patient’s inability to undergo postmastectomy radiotherapy (e. g., periphery—namely, from the second intercostal space into the due to a funnel-chest deformity) or difficult radiological follow- inframammary fold and from alongside the sternum into the up may also be indications. anterior axillary line. The glandular tissue is then dissected The term “modified radical mastectomy” is derives from Patey from medial to lateral off the chest wall or underlying muscles. (1948), who found in comparative studies that preserving the Subcutaneous dissection can be performed well with scissors; for pectoralis major—in contrast to the radical mastectomy operation dissecting the breast tissue off the chest wall, a scalpel or electro- using Halstedt’s technique (1882)—did not compromise local cautery knife is recommended. There is an increased risk of tumor control. Auchincloss (1963) modified the procedure to bleeding near the parasternal arterial perforators and from preserve the pectoralis minor and level III nodes. The procedure superficial veins traveling diagonally through the upper pole of is still carried out in this fashion today. the breast. Bleeding from larger vessels entering from lateral also Modified radical mastectomy is defined as a total mastecto- has to be controlled. my—that is, complete removal of the mammary gland, including In modified radical mastectomy, classic axillary dissection is the nipple–areola complex. The skin envelope, including the performed en bloc. Dissection is carried from the peripheral pectoralis fascia, is preserved for primary wound closure. Level projections of the breast tissue over the lateral border of the I and II axillary lymph nodes are dissected. It remains to be seen pectoralis directly into the axillary adipose tissue. Further expo-