ORIGINAL ARTICLE

Skin-Reducing Subcutaneous Mastectomy Using a Dermal BarrierFlap and Immediate Breast Reconstruction with an Implant:A New Surgical Design for Reconstruction of Early-Stage BreastCancer

Yalcin Bayram • Yalcin Kulahci • Ceyhun Irgil •

Murat Calikapan • Nurettin Noyan

Received: 19 May 2009 / Accepted: 19 November 2009 / Published online: 31 December 2009

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009

Abstract

Background The development of skin-sparing mastec-

tomy techniques for early-stage breast cancer has opened a

new era in reconstructive breast surgery. Because of

improved early diagnoses, the demand for skin-sparing

techniques continues to increase more than ever.

Methods Between March 2006 and April 2008, skin-

reducing subcutaneous mastectomy (SRSM) using the

dermal barrier flap technique and simultaneous breast

reconstruction with silicone implants was performed for 15

patients (a total of 26 breasts) who had either a diagnosis of

early-stage breast cancer or indications for prophylactic

mastectomy. Of the 15 patients, 11 underwent bilateral

reconstruction. The remaining four patients underwent

unilateral reconstruction using SRSM with the dermal

barrier flap technique.

Results The average age of the patients who underwent

SRSM with the dermal barrier flap was 45.7 years. All the

patients were discharged from the hospital on postoperative

day 1. The mean follow-up period was 12 months, and the

recovery time was 35 days. Excellent aesthetic results and

uneventful healing were obtained for 23 breasts. Partial

nipple–areola necrosis occurred in two breasts. Total skin

necrosis in the bilateral nipple–areola and central breast

region occurred for one patient who underwent bilateral

SRSM. Prosthesis exposure was not observed for any of

these patients.

Conclusions The authors present their early results with

SRSM using the dermal barrier flap and silicone implants

for early-stage breast cancer. The dermal barrier flap

became a reliable procedure by providing a decreased breast

envelope, eliminating the risk of implant exposure, and

forming a double layer of dermal tissue at the incision line.

Keywords Dermal barrier flap � Early-stage breast

cancer � Implant � Skin-reducing subcutaneous mastectomy

Breast cancer surgery has evolved from radical mastec-

tomy, with excision of as much tissue as possible, to sub-

cutaneous mastectomy, with sparing of as much tissue as

possible. Notably, the choice of the procedure depends on

both the location and the stage of the cancer. The devel-

opment of diagnostic imaging techniques has increased the

medical profession’s awareness of breast cancer and led to

earlier diagnoses.

Because a greater percentage of cancers are detected

at earlier stages, the need for skin-sparing techniques has

increased. Ongoing controversies continue to debate the

issues of skin-sparing mastectomy and sparing of the

nipple–areola complex. These controversies are focused

This study presented at: 13th Turkish Society of Aesthetic Plastic

Surgery Congress & ISAPS Course, 19–22 June 2009, Hilton

Convention Center, Istanbul-Turkey.

Y. Bayram

Department of Plastic and Reconstructive Surgery,

Bursa Military Hospital, Bursa, Turkey

Y. Kulahci (&) � N. Noyan

Department of Plastic and Reconstructive Surgery, Gulhane

Military Medical Academy and Medical Faculty, Haydarpasa

Training Hospital, Selimiye Mah. Tıbbiye Cad., Kadikoy, 34668

Istanbul, Turkey

e-mail: yakulahci@yahoo.com

C. Irgil

Bursa Breast Surgery Clinic, Bursa, Turkey

M. Calikapan

Department of General Surgery, Bursa Oncology Hospital,

Bursa, Turkey

123

Aesth Plast Surg (2010) 34:71–77

DOI 10.1007/s00266-009-9452-7

on problems of nipple–areola survival and the reliability

of methods from an oncologic point of view. Many

published reports describe the reliability of subcutaneous

mastectomy under certain indications [1–6]. In early-

stage breast cancer, immediate breast reconstruction after

subcutaneous mastectomy is used with increasing

frequency.

Recently, prophylactic mastectomy has been performed

for patients displaying the following oncologic risk factors:

a positive family history, BRCA-1 and -2 gene mutation,

atypic ductal hyperplasia, a history of skin cancer, intensive

lobular carcinoma in situ, and ductal carcinoma in situ.

Prophylactic mastectomy has been performed increasingly

due to either patient demand or oncologic surgeon proposal

[7–9]. Sparing of the nipple–areola complex is extremely

important for aesthetic results and patient satisfaction in

both early-stage breast cancer and high-risk groups [10].

Although subcutaneous mastectomy offers excellent

cosmetic results with small breasts, obtaining optimum

results for moderate-sized and large breasts is more chal-

lenging and requires repositioning of the areola as well as

decreasing the breast skin surface area. Furthermore,

problems with wound healing and jeopardized nipple–

areola survival both exist with large breasts. Finally,

exposure of the implant and failure of reconstruction often

become inevitable.

This report describes our early results with breast

reconstruction using skin-reducing subcutaneous mastec-

tomy (SRSM) and silicone implants for early-stage breast

cancer. A dermal barrier flap has been designed to avoid

problems with nipple–areola survival and wound healing of

ptotic breasts. The flap has eliminated exposure of the

implant during the use of excess skin.

Materials and Methods

Between March 2006 and April 2008, SRSM using the

dermal barrier flap technique and simultaneous breast

reconstruction with a silicone implant was performed for

15 patients (a total of 26 breasts) who had either a diag-

nosis of early-stage breast cancer or indications for pro-

phylactic mastectomy at the Bursa Breast Surgery Clinic

and the Bursa and Kayseri Military Hospital, Department

of Plastic and Reconstructive Surgery. Of the 15 patients,

11 (73.3%) underwent bilateral reconstruction. The

remaining four patients had high risks of breast cancer

other than the diagnosed cancer in the opposite breast

(fourth patient selection criteria) but did not agree to the

procedure for the healthy breast. These four patients

underwent unilateral reconstruction using the dermal bar-

rier flap technique.

Patient Selection

All the patients who had moderate-sized ptotic breasts and

no history of previous reduction mammoplasties underwent

SRSM with a barrier dermal flap. Breast ultrasound was

performed for all the patients, and mammography was

performed for the patients older than 40 years according to

the oncologic diagnostic criteria for those admitted to the

center. Fine-needle aspiration biopsy was performed for

suspicious lesions. The following subcutaneous mastec-

tomy criteria were accepted as suitable oncologic criteria

for SRSM: stage 1 or 2 (early-stage) cancer and mass with

peripheral localization.

Table 1 summarizes the demographic characteristics of

the patients. All the patients were informed about the

surgical procedure, the details of their breast disease, the

risk factors of redundant breast tissue, and the possible

advantages and disadvantages of the surgical technique.

Prophylactic mastectomy was performed for a total of nine

breasts in five patients at high risk. Four findings deter-

minant of a high risk for breast cancer were accepted as

criteria: positive family history, disease disseminated in the

breast (mass or cyst), suspicious areas or calcifications

shown by mammography, and diagnosed cancer in the

opposite breast.

If one or more of these criteria were present, the patient

was informed about the relevant risks. We offer prophy-

lactic mastectomy to the patients who have one or more of

these criteria as well as an extreme fear of breast cancer

[11–13]. Prophylactic SRSM with a dermal barrier flap and

immediate breast reconstruction with implants was per-

formed for the patients who accepted the operation.

Preoperative Planning

Operation planning was performed with patients in the

standing position. First, the region of the mass nearest the

skin was marked, followed by marking of the inframam-

mary fold. As shown in Fig. 4a, a distance of 4 cm between

the inframammary sulcus (IMS) and the nipple is the

projectional distance on the sternum. On the breast, it

becomes 5–7 cm. The distance from a to b in Fig. 1a is

planned as 6 cm.

At the beginning of planning, drawing the projection of

the IMS on the sternum shows whether there is any vertical

asymmetry with the thorax. Generally, 1–2 cm of asym-

metry between the IMS and thorax is common. Showing

this situation is helpful in planning to achieve postoperative

symmetry. The new nipple projection is drawn 4 cm. above

the IMS projection on the sternum. A horizontal line is

drawn from this mark to the breast to determine the new

nipple position. The distance between the new nipple

72 Aesth Plast Surg (2010) 34:71–77

123

position and the sternal notch is measured to make both

nipple distances equal.

We marked the new position of the nipple–areola

complex as 4 cm above the inframammary fold. Operation

planning then was performed according to the superior

pedicle reduction mammoplasty technique. To decrease

tension in the suture line, our preparations left more skin

intact than conventional breast reduction (Figs. 1, 2a–c, 3a,

Table 1 Patient demographic data

Patient no. Preoperative

diagnosis

Type of surgery No. of

breasts

Prophylactic

mastectomy (n)

Complication TNM classification/

pathologic diagnosis

Oncologic

treatment

1 Left breast ca Bilateral SRSM 2 2 – TxN1M0 CT ? RT ? HT

2 Right breast ca Bilateral SRSM 2 1 – T1N1M0 CT ? HT

3 Left breast ca Previous left SSM,

right SRSM

1 1 – T1N2M0 CT ? RT ? HT

4 Left breast ca Bilateral SRSM 2 1 – TisN0M0 –

5 Left breast ca Bilateral SRSM 2 1 – T2N0M0 HT

6 Left breast ca Bilateral SRSM 2 1 Total nipple–areola

necrosis in two

breasts

T1N0M0 CT ? HT

7 Right breast ca Bilateral SRSM 2 1 – T2N0M0 CT ? HT

8 Left breast ca Bilateral SRSM 2 1 – T1N0M0 HT

9 Left breast ca Bilateral SRSM 2 1 – T1N0M0 HT

10 Right breast ca Right SSM,

left SRSM

1 1 – T2N0M0 CT ? HT

11 High risk Bilateral SRSM 2 2 Partial nipple–

areola necrosis

Normal breast tissue –

12 High risk Left SRSM 1 1 – Fibrocystic changing,

epithelial hyperplasia,

adenosis

–

13 High risk Bilateral SRSM 2 2 – TisN0M0 –

14 High risk Bilateral SRSM 2 2 – DIN 1b HT

15 High risk Right SRSM 1 1 Partial nipple–

areola necrosis

Fibrocystic changing,

ductal ectasia,

sclerosing adenosis

HT

TNM tumor node metastasis, CT chemotherapy, RT radiotherapy, HT hormonotherapy, ca cancer, SRSM skin-reducing subcutaneous mastec-

tomy, SSM skin-sparing mastectomy (performed elsewhere)

Fig. 1 Schematic presentation

of the surgical technique. aPreoperative incision planning.

The area inside the planned

incision is deepithelialized

except for the nipple–areola.

The lateral vertical incision is

performed from line a to line b.

The a–b distance is planned as

6 cm. b Final appearance.

Deepithelialization of the

dermal barrier flap without skin

excision. Note the shaded areas

marked behind the suture line,

which represent the dermal

barrier flap that has created an

extra layer

Aesth Plast Surg (2010) 34:71–77 73

123

and 4a). Using this technique, much more breast skin

reduction was achieved, and the final scar was located at

the inferior mammary sulcus.

Operative Procedure

The area between the marked incisions were deepithelial-

ized except for the nipple–areola complex (diameter, 4–

4.5 cm). Total subcutaneous mastectomy was performed

from the lateral vertical incision via a full incision (Figs. 1a

and 2c). Cooper’s ligament, oncologically reliable and

harmless for the subdermal plexus, was followed as a

surgical plan during mastectomy. The pathologic specimen

beneath the nipple–areola complex was marked. Axillary

dissection was performed from the same incision when

needed. Axillary lymph node dissection was performed for

seven patients whose intraoperative sentinel lymph node

biopsy results were positive. Dissection was not performed

for three patients who had negative sentinel node results.

All reconstructions were performed using CPG 323

Cohesive III, medium, and high-profile silicone gel-filled

breast implants with a teardrop shape (Mentor, Canada).

The nipple–areola complex was moved to the planned

position, and the deepithelialized skin surrounding it was

sutured to its peripheral deepithelialized border. The der-

mal barrier flap, this deepithelialized area in the mid-

inferior region, was moved laterally without folding, and

the lateral and medial incisions were sutured to each other

(Fig. 1b). Drains were inserted and left in place for about

10–14 days. Tight bandages and breast girdles were used

for 4–6 weeks.

Results

The average age of patients who underwent SRSM was

45.7 years. All the patients were discharged from the

hospital on postoperative day 1. For all the patients, 560–

890 g per breast was resected. No blood transfusions were

required. The mean follow-up period was 12 months, and

the recovery time was 35 days. For 23 breasts, excellent

aesthetic results and uneventful healing were obtained with

increased patient satisfaction (Figs. 2d–i, 3b–g, and 4b–e).

Partial nipple–areola necrosis occurred in two breasts

(7.7%). One implant was replaced with a smaller implant in

one breast. Debridement and primary repair were per-

formed for another breast in which partial necrosis devel-

oped. Total skin necrosis at the bilateral nipple–areola and

Fig. 2 A 55-year-old patient

with a positive family history

and suspicious

microcalcification areas, as

shown by mammography. The

patient underwent bilateral

prophylactic skin-reducing

subcutaneous mastectomy

(SRSM) due to a high risk for

breast cancer. Pathologic

diagnosis was reported as

carcinoma in situ. a, bPreoperative planning for

bilateral SRSM. c After

completion of the planned skin

incision, deepithelialization, and

mastectomy, a close-up view of

the barrier dermal flap and its

thickness is seen. Subcutaneous

mastectomy was performed

from the lateral incision without

skin excision. d–f Appearance

of the patient 3 months

postoperatively. g–i Appearance

of the patient 2 years

postoperatively

74 Aesth Plast Surg (2010) 34:71–77

123

central breast region occurred for another patient who

underwent bilateral SRSM (7.7%) (Table 1).

Becker 35 prostheses were placed after debridement in

patients who had bilateral total necrosis. Heavy smoking

(1� pack/day for 15 years) was determined to be the

etiology for this patient. Inflation of the prosthesis and

reconstruction of the nipple–areola were obtained

uneventfully in this case. There was no wound dehiscence

at the vertical incision lines. Prosthesis exposure was not

observed in either of these patients.

Fig. 3 A 44-year-old patient

with a positive family history

and suspicious

microcalcification areas, as

shown by mammography. This

patient underwent bilateral

prophylactic skin-reducing

subcutaneous mastectomy

(SRSM) due to a high risk for

breast cancer. The pathologic

diagnosis was reported as

carcinoma in situ. aPreoperative planning. Note the

asymmetry of the breasts. b–dAppearance of the patient

2 months postoperatively. e–gAppearance of the patient

2 years postoperatively

Fig. 4 A 40-year-old patient who underwent bilateral prophylactic

skin-reducing subcutaneous mastectomy (SRSM). a Appearance of

the preoperative planning for the patient. The nipple–areola was

planned as 4 cm superior to the inframammary sulcus. The 4-cm

distance between the inframammary sulcus (IMS) and the nipple is

the projectional distance on the sternum. On the breast, it becomes 5–

7 cm. The distance from a to b in Fig. 1a is planned to be 6 cm. The

new nipple projection is drawn 4 cm above the IMS projection on the

sternum. The distance between the new nipple position and the sternal

notch is measured to make both nipple distances equal. b, cAppearance of the patient 4 months postoperatively. d, e Appearance

of the patient 18 months postoperatively

Aesth Plast Surg (2010) 34:71–77 75

123

Positive axillary lymph node metastases were reported

for three patients. The results of the pathologic investiga-

tions are demonstrated in Table 1. In the postoperative

period, chemotherapy, radiotherapy, and hormonotherapy

were administered to patients when needed (Table 1). For

three patients, flushing, sensitivity, and edema were

observed after chemotherapy in three breasts at the site

where axillary dissection was performed. Recovery was

obtained with palliative medical treatment for these

patients.

Discussion

Confusion still exists about mastectomy procedure termi-

nology. The term ‘‘subcutaneous mastectomy’’ was used to

denote benign breast lesions for the first time by Freeman

[14]. This term means excision of the breast gland and

sparing of the nipple–areola. The term ‘‘skin-sparing

mastectomy’’ was used for excisions of the breast gland,

the nipple–areola, and biopsy scars for the first time by

Toth and Lappert [15] in 1991. The term ‘‘skin-reducing

mastectomy’’ was used for the first time by Nava et al. [16].

With this technique, the nipple–areola is not spared but

either immediately reconstructed as a graft or later recon-

structed with other methods. ‘‘Skin-sparing mastectomy

with nipple–areola complex preservation’’ was the termi-

nology preferred by Vlajcic et al. [6]. In the current study,

we used the term ‘‘skin-reducing subcutaneous mastec-

tomy’’ for the first time. This term means reduction of

breast skin without skin excision while subcutaneous

mastectomy is performed.

Although subcutaneous mastectomy is a reliable method

for patients who have early diagnosed peripheral tumors [5,

6, 17, 18], prophylactic mastectomy is performed for the

opposite-side breast at the patient’s request. In addition,

prophylactic mastectomy is performed for patients at high

risk for breast cancer. Patients who have risk factors can be

followed closely by clinical examinations, mammography,

and magnetic resonance imaging when needed. It should be

emphasized to the patients that although prophylactic

mastectomy reduces their breast cancer risk, this technique

does not eradicate risk altogether [12, 19]. In the current

study, BRCA-1 and BRCA-2 mutation and risk analysis

were not performed routinely because they are not a

common practice in our city and require sending patients to

another city. Thus, they were not used as criteria for pro-

phylactic mastectomy.

In the context of reconstructive surgery, the most

important part of the breast organ is the nipple–areola

complex due to its distinct sensation and its major roles in

aesthetics and function. Reconstruction of the nipple–are-

ola complexes after mastectomy usually is not satisfactory

to the patient [20, 21]. Thus, nipple–areola complex–

sparing mastectomies performed for peripheral tumors

diagnosed at an early stage represent a surgical treatment

choice that maximally increases breast aesthetics.

Surgical methods developed for repositioning the nip-

ple–areola in ptotic breasts depend on excision of excess

skin and reconstruction of the nipple–areola with breast-

reduction incisions. The incisions performed to decrease

the excess skin may cause healing problems at the incision

lines and also deteriorate nipple–areola survival. The sur-

gical technique presented in this report to reduce excess

skin and facilitate repositioning of the nipple–areola in

mid-sized breasts increases nipple–areola survival by pro-

tecting the inferior dermal pedicle. The only incision that

may jeopardize tissue oxygenation with the proposed

technique is the lateral incision performed for mastectomy.

This incision allows both sentinel node biopsy and axillary

dissection.

Wound-healing problems usually are not encountered

during subcutaneous mastectomies with no skin reduction.

Skin blood perfusion is jeopardized during breast reduction

mastectomy. Two mechanisms can be proposed that

explain these wound-healing/perfusion issues: long flaps

created as a result of skin excision and aggressive surgery

that causes very thin skin and jeopardizes the subdermal

plexus [16].

With the surgical technique used in this study, full-cut

incisions from only the lateral side and deepithelialization

instead of skin excision reduces wound-healing problems at

suture lines. Use of the inferior dermal barrier flap provides

double-layered protection at the suture site and avoids

implant exposure even when wound dehiscence occurs.

Although the submuscular area is more protective of the

prosthesis [22], it is not optimal for larger prostheses.

Pressure on the prosthesis can cause low-level breast pro-

jection. In addition, preparation of the submuscular area

increases the mean time for the surgical procedure.

Good aesthetic results can be obtained with subcutane-

ous placement in the early period. However, the weight of

the prosthesis which skin must bear, may cause complaints

of early ptosis, rotation of prosthesis, protrusion of the

prosthesis, and undulation of the skin surface due to

prosthesis pulling. In the study presented here we not

encountered with this problem. Especially in young

patients for whom prophylactic mastectomy (risk-reducing

surgery) is planned, subcutaneous implantation can be

performed reliably because the skin is not very thin, as is

found with patients who have undergone aggressive sur-

gery due to diagnosed breast cancer.

With breast cancer surgery, surgical interventions to

protect the nipple–areola are worthy of testing and dis-

cussion. In the current study, total necrosis of the nipple-

areola occurred with an incidence of 7.7%. We consider

76 Aesth Plast Surg (2010) 34:71–77

123

this an acceptable risk level. Our experience using this

technique is that increased breast dimension, increased

degree of ptosis, and smoking increase the rate of com-

plications. To determine a reliable zone for this technique,

more experience and a large series of cases are needed.

Conclusion

For patients who plan to undergo subcutaneous mastec-

tomy but have breast cancer or are at high risk for breast

cancer (candidates for prophylactic mastectomy), a silicone

implant is the easiest choice as a reconstruction material. If

these patients have moderate-sized and ptotic breasts, it is

necessary to reduce the amount of breast skin and reposi-

tion the nipple–areola to achieve better aesthetic results.

The reducing pattern and the small and useful mastectomy

incisions described with this technique contribute to skin

flap and nipple–areola survival. The inferior dermal barrier

flap used in this study improves reconstruction reliability

by decreasing the breast envelope and forming double-

layered dermal tissue at the incision line. Skin-reducing

subcutaneous mastectomy with a dermal barrier flap and

simultaneous reconstruction with silicone implants are a

good alternative for early-stage breast cancer patients with

moderate-sized breasts.

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