The Intraoperative Team Approach to Nipple-Sparing Mastectomy

Fig. 22.1

Team approach to inframammary nipple-sparing mastectomy . (a) Both oncologic surgeon and plastic surgeon work simultaneously on opposite sides of the table to start the axillary dissection and mastectomy. (b) The tail of the breast is released from the axillary incision while the breast is lifted off the pectoralis major muscle. The superficial inframammary dissection may be started while the sentinel lymph node biopsy is being obtained

After the completion of the sentinel lymph node biopsy the plastic surgeon assists the oncologic surgeon in the mastectomy to perform the following :

1.

Preserve the subcutaneous fat by pushing the fat up against the skin with the back of a DeBakey forceps to expose the anterior mammary fascia and Cooper’s ligaments.
2.

Provide the appropriate counter traction of the breast, particularly in the axillary tail and upper pole of the breast. The subcutaneous dissection in the upper pole is the most difficult part of the inframammary nipple-sparing mastectomy, more so in women with long chests, because of limited visibility and less effective counter traction. The plastic surgeon’s assistance is important here not only to provide exposure and counter traction but, if need be, to also surgically release the breast from a more suitable visual angle.
3.

Ensure that subdermal areola dissection does not exceed 16 cm². Subcutaneous fat thinning up to 25 cm² may be performed in the breast flap provided the thinned area is not contiguous to the areola as this may jeopardize the circulation to the areola skin. The surface area of flap thinning may vary depending on the overall thickness of the flap because thicker flaps tolerate larger areas of thinning.
4.

Protect the skin by minimizing the use of metallic retractors and avoiding excessive skin traction.

In bilateral nipple-sparing mastectomy, we perform the prophylactic side first with the plastic surgeon assisting the oncologic surgeon (Fig. 22.2). After the prophylactic mastectomy is completed, the oncologic surgeon starts the sentinel lymph node biopsy and/or the lymph node dissection on the opposite side while the plastic surgeon reconstructs the preventive mastectomy side with tissue expander. The therapeutic mastectomy and reconstruction are performed last.

Fig. 22.2

The plastic surgeon assisting the oncologic surgeon on the nipple-sparing mastectomy. Dissection of the axillary tail of the breast and the upper pole of the breast is facilitated by the onco-plastic surgical collaboration

With both surgeons working together, operative time for a bilateral nipple-sparing mastectomy and reconstruction may be cut down to less than 3 h. The same is said for a more complex primary mastopexy and nipple-sparing mastectomy [7]. The combined mastopexy-mastectomy procedure should in theory take longer to complete than a nipple-sparing mastectomy because of the deepithelialization of the large inferior flap and closure of the extensive inframammary and periareolar wounds. In actuality, it takes the same amount of time to perform a mastopexy-nipple-sparing mastectomy as it does to complete an inframammary nipple-sparing mastectomy if both surgeons work together.

Intraoperative Decision-Making

Intraoperative decisions regarding the thinning of the breast flaps to clear the tumor are best made by both the oncologic and plastic surgeon. Tumors in the vicinity of the areola require special consideration because of the potential for excessive thinning and resultant nipple/areola loss. If a superficial tumor close to the areola requires thinning of the subcutaneous fat, a decision has to be made whether to remove the entire subareolar breast tissue subdermally, or retain a thin breast layer for removal at the time of the second-stage reconstruction. If both the areola and the adjacent flaps are thinned down to the dermis the likelihood of nipple/areola loss is high.

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