Scar-Free Breast Reconstruction: New Technique

NEW ORLEANS—A new technique for breast reconstruction, used after a new method of skin-sparing mastectomy, offers patients a scar-free result, according to the surgeon who developed the method, Gino Rigotti, MD, head of the Plastic Surgery Department, Verona General Hospital, Italy.

The reconstruction involves insertion of a semilunar-shaped expander followed by definitive implant with a purse-string skin closure, Dr. Rigotti said at the 68th Annual Scientific Meeting of the American Society of Plastic and Reconstructive Surgeons (now known as the American Society of Plastic Surgeons).

From the reconstructive surgeon’s point of view, skin-sparing mastectomy is a contradiction in terms. “Skin-sparing mastectomy is a surgical method that reduces scars in the breast area but still requires very invasive reconstructive techniques,” Dr. Rigotti said.

The most commonly used immediate reconstruction techniques after skin-sparing mastectomy—free and pedicle TRAM flaps or latissimus dorsi flap with implant—are highly invasive and can leave functional or esthetic complications in donor areas in these patients, he said.

To avoid disfiguring scars, Dr. Rigotti developed the new technique based on what he considers the simplest, least invasive reconstruction method available—expansion followed by definitive implant.

The modified reconstruction method uses a purse-string closure to the central portion of the surgical wound, reducing the length and appearance of the scar. Additionally, the expander is not the usual round or oval shape—it is semilunar, a shape, Dr. Rigotti said, that allows the physician to expand only the inferior pole and thus achieve a more desirable shape and position.

In the Verona experience of Dr. Rigotti and his colleague Alessandra Marchi, MD, the complication rate in patients undergoing this method of reconstruction has been low. The major complication rate (complications resulting in failure of the reconstruction) is 3%, and the minor complication rate (complications that did not compromise the reconstruction) is 9%. This low complication rate is due, he believes, to the absence of the retracting longitudinal scars normally present with use of the other methods.

The complication rate is higher in patients who underwent or will undergo radiation therapy. For such patients, autologous tissue procedures are probably a better choice, he said.

The Italian surgeons began using the technique in August 1997 and described their experience in 90 patients over a 26-month period. Of this group, 50 patients had mastectomy followed only by expander introduction, and 40 patients completed the surgical procedure with definitive implant and areola-nipple reconstruction.

Skin excision in these patients was 5 cm to 13 cm wide, and an axillary dissection was made en bloc with the mammary gland when necessary.

Patients with central or paracentral infiltrating cancer or with comedo-type simple or multifocal intraductal lesions received a round, central skin incision, which always included the skin overlying the lump. The only obvious scar left in these patients after reconstruction was the one surrounding the newly reconstructed nipple-areola.

Patients with infiltrating cancer of the peripheral quadrants received a drop-shaped incision, which included the nipple/areola complex and the skin over the lump. The purse-string closure in this group was applied to the central portion of the surgical wound, reducing the length of the residual scar and preventing scar involvement of the tumor-free quadrants.