1. Aesth Plast Surg (2010) 34:71–77
DOI 10.1007/s00266-009-9452-7
ORIGINAL ARTICLE
Skin-Reducing Subcutaneous Mastectomy Using a Dermal Barrier
Flap and Immediate Breast Reconstruction with an Implant:
A New Surgical Design for Reconstruction of Early-Stage Breast
Cancer
Yalcin Bayram • Yalcin Kulahci • Ceyhun Irgil
Murat Calikapan • Nurettin Noyan
•
Received: 19 May 2009 / Accepted: 19 November 2009 / Published online: 31 December 2009
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009
Abstract
Background The development of skin-sparing mastectomy 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, skinreducing 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.
This study presented at: 13th Turkish Society of Aesthetic Plastic
Surgery Congress & ISAPS Course, 19–22 June 2009, Hilton
Convention Center, Istanbul-Turkey.
Keywords Dermal barrier flap Á Early-stage breast
cancer Á Implant Á Skin-reducing subcutaneous mastectomy
Y. Bayram
Department of Plastic and Reconstructive Surgery,
Bursa Military Hospital, Bursa, Turkey
Y. Kulahci (&) Á 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
Breast cancer surgery has evolved from radical mastectomy, with excision of as much tissue as possible, to subcutaneous 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 development 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
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2. 72
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 earlystage 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 challenging 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 mastectomy (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.
Aesth Plast Surg (2010) 34:71–77
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 mastectomy 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 determinant 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 prophylactic 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 performed for the patients who accepted the operation.
Preoperative Planning
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 diagnosis of early-stage breast cancer or indications for prophylactic 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 barrier flap technique.
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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 inframammary 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 asymmetry 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

3. Aesth Plast Surg (2010) 34:71–77
73
Table 1 Patient demographic data
Patient no. Preoperative
diagnosis
Type of surgery
No. of Prophylactic
Complication
breasts mastectomy (n)
TNM classification/
pathologic diagnosis
Oncologic
treatment
1
Left breast ca
Bilateral SRSM
2
TxN1M0
CT ? RT ? HT
2
Right breast ca Bilateral SRSM
3
Left breast ca
4
5
2
–
2
1
–
T1N1M0
CT ? HT
1
–
T1N2M0
CT ? RT ? HT
Left breast ca
Previous left SSM, 1
right SRSM
Bilateral SRSM
2
1
–
TisN0M0
–
Left breast ca
Bilateral SRSM
2
1
–
T2N0M0
HT
6
Left breast ca
Bilateral SRSM
2
1
Total nipple–areola T1N0M0
necrosis in two
breasts
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 mastectomy, SSM skin-sparing mastectomy (performed elsewhere)
Fig. 1 Schematic presentation
of the surgical technique. a
Preoperative 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
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,
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Aesth Plast Surg (2010) 34:71–77
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, b
Preoperative 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
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 deepithelialized 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
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sutured to its peripheral deepithelialized border. The dermal barrier flap, this deepithelialized area in the midinferior 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 performed for another breast in which partial necrosis developed. Total skin necrosis at the bilateral nipple–areola and

5. Aesth Plast Surg (2010) 34:71–77
75
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. a
Preoperative planning. Note the
asymmetry of the breasts. b–d
Appearance of the patient
2 months postoperatively. e–g
Appearance 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, c
Appearance of the patient 4 months postoperatively. d, e Appearance
of the patient 18 months postoperatively
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.
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Positive axillary lymph node metastases were reported
for three patients. The results of the pathologic investigations 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 terminology. 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 reconstructed with other methods. ‘‘Skin-sparing mastectomy
with nipple–areola complex preservation’’ was the terminology preferred by Vlajcic et al. [6]. In the current study,
we used the term ‘‘skin-reducing subcutaneous mastectomy’’ 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 prophylactic 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–areola complexes after mastectomy usually is not satisfactory
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Aesth Plast Surg (2010) 34:71–77
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 nipple–areola in ptotic breasts depend on excision of excess
skin and reconstruction of the nipple–areola with breastreduction incisions. The incisions performed to decrease
the excess skin may cause healing problems at the incision
lines and also deteriorate nipple–areola survival. The surgical 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 protecting 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 projection. In addition, preparation of the submuscular area
increases the mean time for the surgical procedure.
Good aesthetic results can be obtained with subcutaneous 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 surgery due to diagnosed breast cancer.
With breast cancer surgery, surgical interventions to
protect the nipple–areola are worthy of testing and discussion. In the current study, total necrosis of the nippleareola occurred with an incidence of 7.7%. We consider

7. Aesth Plast Surg (2010) 34:71–77
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 complications. 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 mastectomy 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 reposition 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 doublelayered 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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