Is oncologic safety compatible with a predictably viable mastectomy skin flap?

Necrosis with partial loss of mastectomy flaps is an all-too-common complication of otherwise advantageous skin-sparing mastectomies. Central to the problem of predictable flap viability is the thickness of the skin flaps. Seeking a balance between the preservation of adequate flap thickness and maintenance of oncologic principles, the authors sought guidelines to help the oncologic surgeon identify the non-breast-bearing subcutaneous layer of tissue between the epithelial/dermal tissue of the breast and its parenchyma.

Breast specimens of women receiving reduction mammaplasty were prospectively examined by an experienced, blinded breast pathologist. Subcutaneous tissue thickness was measured from caudal dermis to breast parenchyma and correlated with age, body mass index, and breast specimen weight.

No significant correlation was found between body mass index, age, or breast sample weight and the thickness of the subcutaneous tissue. Measurements did reveal a consistent and distinct layer of non-breast-bearing subcutaneous tissue between the dermis and the breast parenchyma, with a median thickness of about 1 cm.

Both oncologic safety and a viable skin flap can be achieved if the subcutaneous layer present in most breasts is used as a guide for elevating the skin flaps, with subsequent oncologically safe resection of the cancer-containing breast parenchyma.