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Skin-sparing mastectomy (SSM) tends to be confined to multidisciplinary practices within designated breast units. Mastectomy and immediate breast reconstruction usually are undertaken either as a joint procedure between a general and plastic surgeon or exclusively by a dedicated breast surgeon with “oncoplastic” training. This may in part account for the “patchy” and variable nature of the responses in the survey conducted by Bleicher et al.,1 as dissemination of the technique throughout the global breast carcinoma community continues.

SSM represents the latest phase in the development of progressively less mutilating forms of mastectomy for breast carcinoma treatment, with early Halstedian procedures removing much of the breast skin envelope.2 However, to my knowledge, the oncologic equivalence of SSM to conventional modified radical mastectomy has never been validated in prospective controlled trials. Undoubtedly, patient demand has influenced surgical practice, and transatlantic differences with regard to familiarity and knowledge of SSM techniques are evident. Some individuals felt sufficiently confident to complete the survey, yet displayed a fundamental flaw in their knowledge of reconstructive options within the context of SSM. It is reassuring that nearly 90% of surgical oncologists were familiar with the literature base for SSM, although levels of skepticism exist that are inversely related to the degree of surgical involvement in the SSM procedure itself. The authors allude to the dominance of plastic surgery journals as a vehicle for the publication of articles on SSM despite two of the seminal works on this subject appearing in cancer journals (one of which has a breast surgeon as the first author3).3, 4

The precise patterns of incision and the extent of skin resection must be tailored to individual cases. There is a risk of oncologic compromise when standard incisions are adopted in a blanket manner or when general surgeons are coerced into performing “pure” skin-sparing resections when these are inappropriate. Plastic surgery colleagues must respect oncologic mandates and be prepared to sacrifice additional native breast skin when indicated. Increasing numbers of patients are receiving postmastectomy radiotherapy and the Survey by Bleicher et al.1 revealed that nearly half of radiation oncologists would be “more aggressive” with radiotherapy regimens after SSM techniques. This may have implications for patients with implant-based reconstructions, for whom hypofractionated dosage has been employed to minimize capsular contracture. Long-term data regarding rates of loco-regional recurrence and distant recurrence will clarify relative indications for SSM, but in the interim, patient selection criteria and quality control issues must be scrutinized constantly and subjected to ongoing audit and evaluation.5

REFERENCES

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  • 1
    Bleicher RJ, Hansen NM, Giuliano AE. Skin-sparing mastectomy: specialty bias and worldwide lack of consensus. Cancer. 2003; 98(: 23162321.
  • 2
    Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital. Ann Surg. 1907; 46: 119.
  • 3
    Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol. 1999; 6: 676681.
  • 4
    Rivadeniera DE, Simmons RM, Fish SK, et al. Skin-sparing mastectomy with immediate breast reconstruction: a critical analysis of local recurrence. Cancer J. 2000; 6: 331335.
  • 5
    Greco M, Querci della Rovere G, Benson JR, et al. Skin-sparing and skin reducing mastectomy. In: Querci della RovereG, BensonJR, BreachN, NavaM, editors. Oncoplastic and reconstructive surgery of the breast. London: Martin Dunitz, 2004: 2132.