Preoperative Markings

The day before surgery, the surgeon must discuss with the patient the planned surgical approach and the final location of the scars. The breasts are analyzed with the patient in the standing position, and any asymmetry of breast shape, size, or areolar position should be noted and discussed with the patient.

Asymmetry may be caused by increased breast volume from the tumor or residual edema or hematoma after previous biopsies. Such asymmetry should be distinguished from congenital asymmetry.

The midline should be marked between the breasts and inframammary folds. These markings are used to assess symmetry after the operation. The planned skin incisions are drawn in permanent marker with the patient still standing. There is general agreement among breast surgeons that radial incisions are performed in the lower middle part of the breast and circumareolar incisions in the upper middle part.

This patient shows good scar positioning, with asymmetry of the NAC.

This patient’s postoperative results after right breast radiotherapy are satisfactory. The left NAC was relocated.

A circumareolar incision in the inferior quadrants could create a disfiguring crease between the areola and the inframammary fold. A radial scar in the upper part of the breast may be too visible if it exceeds the décolleté line. This patient shows poor results, because the radial scar is evident in the décolleté area and the external position of the NAC.

Periareolar ⁵ incisions provide good results if the tumor is located close to the areola; otherwise extended skin undermining can leave disfiguring skin retractions. Subareolar tumors can be performed by periareolar excision of the NAC and tumor, with purse-string closure and glandular plication (A through E). When the tumor is located in the upper outer quadrant, a radial scar allows good exposure of the tumor site, but it is recommended that the scar be lowered to avoid crossing the décolleté line. If the scar must extend toward the axilla for lymph node dissection, using a broken line is suggested to decrease scar contraction and skin retraction.

This patient had a central tumor (A). She is shown after a central quadrantectomy with a glandular defect, skin undermining, gland closure, and purse-string skin closure (B).

The need for skin resection generally depends on the possible connection between the tumor and the dermis, especially tumors located superficially in the gland. When the tumor is deeper within the glandular tissue, an inframammary incision works well.

The marking should be made 1 cm above the inframammary fold to ensure that it will not be visible under the bra. The length of the incision should be 5 to 6 cm but can easily be extended toward the axilla to perform a sentinel node biopsy or complete node dissection. An inframammary incision with extensive undermining of the breast allows the surgeon to explore the whole breast and remove a tumor in any quadrant, without modifying the breast’s shape. The patient shown here underwent a radio-active, probe-guided tumorectomy using a retroglandular approach and an inframammary incision.