There are more than 4000 chemicals present in cigarette smoke, including nicotine and carbon monoxide.¹ One effect of nicotine is to cause vasoconstriction of the dermal–subcutaneous vascular plexus. This has important consequences, as mastectomy flaps rely on this plexus for survival.² As well as inducing a hypoxic state and causing vasoconstriction, smoking can lead to increased platelet aggregation, which results in the formation of tiny thromboses in capillaries. This is detrimental to wound healing, which relies heavily on blood flow in newly formed capillaries. Smokers have higher levels of fibrinogen and haemoglobin, which increase blood viscosity, which further increases the likelihood of blood clotting, and blood velocity can be reduced by up to 42% in smokers.³ The combination of decreased oxygen delivery to tissues and the thrombogenic effects of smoking, together with increased viscosity and reduced velocity, explain why wound healing in smokers is significantly impaired.

The link between smoking and wound healing was first documented in the 1970s. One study of 425 patients undergoing mastectomy and breast-conserving surgery identified smoking as an independent predictor for wound infection and skin necrosis regardless of the number of cigarettes smoked.⁴

Another study of 716 patients having free transverse rectus abdominis myocutaneous (TRAM) flaps showed mastectomy flap necrosis, abdominal flap necrosis and abdominal hernias were significantly higher in smokers.⁵ This study did demonstrate a dose effect with smokers who had a history of more than a pack a day for 10 years being at increased risk of developing problems compared with smokers who had smoked for a smaller number of pack years (55.8% vs. 23.8%). One observation in this study was that delayed breast reconstruction in smokers was associated with a significantly lower rate of wound complications compared with immediate breast reconstruction in smokers. The risk of wound complications in delayed reconstructions in smokers was similar to the rate in non-smokers. Complications were also less common in women who stopped smoking 4 or more weeks before surgery.

There was one small study of 108 patients investigating smoking cessation prior to surgery that was a randomised clinical trial with 40 patients in the control group and 68 patients in the interventional group.⁶ Patients assigned to intervention were given counselling and nicotine replacement therapy. This study showed a significant reduction in complications in the intervention group, with a reduction in both wound-related complications and the need for secondary surgery.

In this study patients stopped smoking 6–8 weeks before surgery and did not smoke for 10 days after the operation. In the literature there is no consensus on the optimal duration of preoperative smoking cessation but there is evidence from a variety of studies that there are potential benefits from even a brief period of abstention. Part of the problem is that the majority of studies are retrospective and have inherent weaknesses in their design.

Considerations for simple mastectomy

In addition to general considerations, four questions should be answered:

1. Is it necessary/desirable to excise skin overlying the cancer?

In principle, skin only requires to be excised if the cancer is involving the skin or is so close that a clear margin cannot clearly be achieved around the cancer without skin resection.

2. Is there likely to be a lateral dog ear/redundant tissue?

The all too frequently seen but completely avoidable complication of mastectomy is redundant tissue, also known as a dog ear, which is unsightly, causes difficulty with bra fitting and often chafes on the prosthesis, arm or bra (Fig. 5.1).

Figure 5.1 Poor result from mastectomy.

3. Would the patient benefit from a contralateral breast reduction?

This is a simple and very effective option to enable women with a heavy breast to wear a lighter prosthesis and feel less unbalanced (Fig. 5.2a). In some cases a woman may choose a bilateral mastectomy to achieve better overall symmetry.

Figure 5.2 (a) A low mastectomy scar with contralateral reduction. (b) Delayed reconstruction with LD flap.

4. Is a delayed breast reconstruction planned?

The scar should be sympathetic to the method of delayed reconstruction planned. In most cases a low scar is best (as in Fig. 5.2a). It allows a flap-based reconstruction to be set at the inframammary fold, with the upper scar low enough to be hidden in low- neckline clothes (Fig. 5.2b).

Planning a mastectomy

• Examine the patient sitting up to assess lateral tissue and plan the likely lateral end of scar. The predicted lateral extent of the incision can be marked.

• The extent of the scar is important if radiotherapy is planned as the whole scar will be covered and can result in large volumes of tissue being treated if the scar extends a long distance posteriorly.

• Mark any skin that needs to be removed over the cancer.

• Decide if a second incision is required for sentinel node biopsy (usually not necessary).

Technique

Most scars can be based around the inframammary fold (IMF). The incision pattern is drawn in theatre initially with a line at or just below the IMF (in women with any intertrigo the scar should be placed below this). Then with repeated upward and downward movement of the breast the planned transposition of this line on the breast skin can be marked (Fig. 5.3). In most cases the upper incision line passes a little above the areola. Attention should be paid to the degree of tension applied to the upward or downward breast movement as this represents the tension that will be exerted on the wound on closure. The upper and lower incision lines should be planned so that they meet comfortably but without excess laxity. Incisions should be planned to avoid any dog ear. To achieve this it is often best to continue the incision along the bra line laterally, curving up slightly until the upper and lower lines meet (Fig. 5.4) or, if there is doubt about how to fashion the lateral end, stop the incision at the lateral edge of the breast and fashion it once the mastectomy is complete, before closure (see comments regarding dog ear below). Transverse mastectomy scars are commonly used but rarely, if ever, can be closed without significant excess of tissue, particularly laterally. It is beholden on all surgeons to be familiar with a range of mastectomy incisions and given that there are always better alternatives, transverse mastectomy scars should be avoided.

Figure 5.3 Drawing of IMF-based incision.

Figure 5.4 IMF-based incision with lateral extension.

Inferior broad-based flaps can be designed to allow skin excisions in the upper pole. In breasts with a high nipple position or in cases where skin excision in the upper pole is desired, the lower incision line can be adjusted to preserve skin on the lower flap. Such modifications to the inferior skin flap should be broad based. Other scar patterns to consider in such situations include the Wise pattern or dome-shaped scar (Fig. 5.5).

Figure 5.5 Dome-type mastectomy scar to allow excision of upper pole skin.

Lighting: A headlight is valuable and should be part of the equipment available for any breast operation.

Retraction: Care should be taken with the edges of the mastectomy flaps. Sharp hooks or tissue forceps applied to dermis cause less trauma to mastectomy flaps than blunt retractors.

Identifying the ‘plane’: Some would contest its existence, but there is a readily identifiable plane between the breast and subcutaneous fat that defines the dissection. That is not to say that it is obvious in every case and it may be quite irregular. The thickness of fat on mastectomy flaps varies between patients and increases further the distance from the nipple. Importantly, however, the subcutaneous vessels (extensions of the intercostal perforators) lie superficial to this plane. The plane can be defined by hydrodissection infiltrating saline (I use 1 in 1 million – others use 1 in 500 000)/adrenaline using a spinal needle, Verres needle or blunt infiltration cannula attached to a 50-mL syringe or a pressure bag (100–150 mmHg) of saline/adrenaline solution. The plane is identified as a white line after performing a skin incision before the flaps are lifted and retracted. With opposing retraction on skin and breast and light initial dissection, tissues are seen to separate at the level of the plane. Dissection then chases this white line with continued opposing retraction (with skin hook retraction on the upper flap, skin kept as straight as possible), cutting on its superficial surface. This produces a flap of uniform thickness that will be thicker in fatter women and thinner in others.

Surgical tools: My preference is to use a hand-held diathermy on a fulgurate setting throughout. If using hydrodissection, scissors or a knife can be used as the plane is bloodless. Different surgeons have different preferences. Blood loss should be less than 100 mL if diathermy is used. Some prefer scissors or the knife because of concern of the ‘burn’ that results from diathermy dissection; blood loss is generally greater with scissors or the knife.

Preserving the intercostal perforators: These represent the main blood supply to the mastectomy flaps once the breast tissue is removed. Their preservation is important, not just for the prevention of flap necrosis and wound problems, but also to maximise the longer-term quality of the skin. The largest tend to originate at the second or third intercostal space. These are usually encountered early in the dissection just superior to the areola and can be seen (especially in thin women) and preserved during dissection upwards and medially.

Issues regarding posterior margin: Strong opinions are often expressed regarding whether or not to excise the pectoral fascia and when to excise some muscle. The posterior plane or breast plate is very well defined, certainly in the middle and upper part of the breast. In these areas there is no need and no clinical evidence to support removal of the pectoral fascia. For mastectomy, preservation of the fascia is only an issue if the cancer lies posterior in the breast. If this is the case and there is any doubt about adherence to muscle, then a portion of pectoral muscle can also be taken. In such situations a wide margin of muscle excision avoids the situation where a margin is reported as histologically involved or close (often due to its contraction following fixation), at no additional cost in terms of morbidity.

Inframammary fold: With a simple mastectomy this is normally excised, avoiding a ridge and producing a flat surface.

The anterior fat over the shoulder: This is often prominent and yet not part of the breast. If not contoured, it can produce a bulge in the upper outer aspect of the mastectomy site. Undermining the upper flap towards the shoulder often releases this fat pad so that it is more evenly distributed.

A flat surface: After mastectomy, before closure, the chest wall should be palpated with the flat of the hand to make sure there are no ridges or prominent irregularities. If so, these can be contoured prior to closure. There is some evidence that suturing the mastectomy flaps to the chest wall, so-called ‘quilting’, reduces seroma formation.

Suturing: Interrupted deep dermal sutures to approximate skin edges and gather any discrepancy between upper and lower flaps are advisable prior to a subcuticular suture. My preference is to use 3/0 absorbable suture throughout.

Managing the potential dog ear: Several techniques have been described for this. First and foremost, however, do not use incisions – such as a transverse mastectomy scar – which produces a ‘dog ear’ or ‘angel wings’ in the majority of patients in whom it is used. One approach to reduce ‘dog ears’ is as follows. If the patient is fairly thin, a flat lateral chest wall can be achieved by using an IMF scar as described above. In women with excess lateral tissue, it is often useful to complete the mastectomy with minimal extension of the scar laterally and then tidy this part of the scar. The easiest way to do this is to close the skin with temporary placement of skin staples. This then allows variations of lateral scar closure to be visualised before commitment to any particular one. The staples can be removed and replaced as many times as necessary to get the best and shortest scar. Final wound closure is with two layers of absorbable deep and superficial subcuticular absorbable sutures. Some lateral laxity can be accommodated by gathering the upper flap.

The three most useful techniques for lateral scar design in my experience are lateral extensions of the IMF scar, liposuction and the fishtail technique (Fig. 5.6). When performing fishtailing use staples to approximate the wound edges and take the lateral end of the transverse incision and move it and staple it medially to flatten out the lateral end of the wound to leave two smaller dog ears. Mark out incisions to excise these dog ears and then excise or de-epithelialise these (to preserve blood supply at the ‘T’ where the three wounds meet) to produce the fishtail pattern. Ensure that the wound is flat, if necessary by using liposuction. Liposuction is a useful adjunctive technique in many mastectomies.

Figure 5.6 Fishtail scar with contralateral reduction (correction of case in Fig. 5.1).

Cases in which difficulty with the lateral tissue is predicted preoperatively can be performed either with the patient on their side (ideally) or with some degree of rotation. Women with excess lateral tissue can be challenging cases, and should be managed by those familiar with a range of flap-based surgery as well as liposuction, and be planned preoperatively. Glue provides a dressing that does not need to be changed, is waterproof (so patients can shower next day) and rarely produces skin reaction, so minimising further trauma to the skin surface around the flap edges.

Considerations for mastectomy with immediate reconstruction

Of the general issues listed above, smoking is a particular concern and the major risk factor for flap necrosis and wound problems with skin-sparing mastectomy.⁷ The following questions should be considered:

1. Is it necessary/desirable to excise skin overlying the cancer?

In general terms, the same principles apply as described above. However, immediate breast reconstruction is enhanced by preserving most (if not all) of the breast skin. Studies assessing the safety of this procedure relative to rates of local recurrence are summarised in Table 5.1. Although there are several that report acceptable recurrence rates, no large randomised trial data are available. It seems sensible to apply the same principles as one would for simple mastectomy. In other words, if the cancer is close to skin such that a healthy margin of normal tissue cannot easily be excised around it, then the overlying skin should be resected. An important principle of oncoplastic surgery is that treatment must not be compromised for the sake of cosmesis. Different designs of skin-sparing mastectomy can allow skin excisions at any site.

Table 5.1

Case series of over 100 patients reporting local recurrence rates after skin-sparing mastectomy