Annals of Surgical Oncology

, Volume 21, Issue 10, pp 3223–3230 | Cite as

Total Skin-Sparing Mastectomy and Immediate Breast Reconstruction: An Evolution of Technique and Assessment of Outcomes

  • Frederick Wang
  • Anne Warren Peled
  • Elisabeth Garwood
  • Allison Stover Fiscalini
  • Hani Sbitany
  • Robert D. Foster
  • Michael Alvarado
  • Cheryl Ewing
  • E. Shelley Hwang
  • Laura J. EssermanEmail author
Breast Oncology



Total skin-sparing mastectomy (TSSM) with preservation of the breast and nipple-areolar complex (NAC) skin was developed to improve aesthetic outcomes for mastectomy. Over time, indications for TSSM broadened and our technique has evolved with a series of systematic improvements.


We reviewed all cases of TSSM with immediate breast reconstruction performed from 2005 to 2012. Patient comorbidities, treatment characteristics, postoperative complications, and outcomes were obtained prospectively and through medical chart review. Locoregional recurrences, distant recurrences, and patient survival were analyzed with Kaplan–Meier methods.


During this 8-year period, 633 patients (981 cases) underwent TSSM with median follow-up time of 29 (interquartile range 14–54) months. Immediate breast reconstruction was performed with tissue expander placement (89 %), pedicle TRAM (5 %), free flap (5 %), permanent implant (0.3 %), or latissimus flap (0.2 %). The incidences of postoperative complications decreased significantly over time. In 2012, these were down to 3.5 % for superficial nipple necrosis, 1.0 % for complete nipple necrosis, 3.0 % for minor skin flap necrosis, 4.4 % for major skin flap necrosis, 13.3 % for infections requiring oral antibiotics, 9.9 % for infections requiring intravenous antibiotics, 3.4 % for infections requiring operative intervention, and 8.5 % for expander/implant. Overall 5-year cumulative incidences of recurrence were 3.0 % (locoregional) and 4.2 % (distant), and there were no recurrences in the NAC skin.


Systematic changes in our technique of TSSM and immediate breast reconstruction have decreased postoperative complications over time. Oncologic outcomes of locoregional and distal recurrences remain similar to skin-sparing mastectomy techniques.


Breast Reconstruction Distant Recurrence Locoregional Recurrence Nipple Acellular Dermal Matrix 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Hani Sbitany, MD is a member of the speaker’s bureau for LifeCell Corporation. He did not receive any compensation or financial support for this study. The remaining authors have no financial interest in any of the products or devices mentioned in this article.


  1. 1.
    Warren Peled A, Foster RD, Stover AC, et al. Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol. 2012; 19(11):3402–9.PubMedCrossRefGoogle Scholar
  2. 2.
    de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol. 2011;18(11):3117–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol. 2011;18(6):1665–70.PubMedCrossRefGoogle Scholar
  4. 4.
    Stanec Z, Zic R, Budi S, et al. Skin and nipple-areola complex sparing mastectomy in breast cancer patients: 15-year experience. Ann Plast Surg. Dec 25 2013.Google Scholar
  5. 5.
    Munhoz AM, Aldrighi CM, Montag E, et al. Clinical outcomes following nipple-areola-sparing mastectomy with immediate implant-based breast reconstruction: a 12-year experience with an analysis of patient and breast-related factors for complications. Breast Cancer Res Treat. 2013;140:545-55.PubMedCrossRefGoogle Scholar
  6. 6.
    Mallon P, Feron JG, Couturaud B, et al. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg. 2013;131(5):969–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Garwood ER, Moore D, Ewing C, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg. 2009;249:26–32.PubMedCrossRefGoogle Scholar
  8. 8.
    Mukhtar RA, Throckmorton AD, Alvarado MD, et al. Bacteriologic features of surgical site infections following breast surgery. Am J Surg. 2009;198(4):529–31.PubMedCrossRefGoogle Scholar
  9. 9.
    Peled AW, Foster RD, Esserman LJ, Park CC, Hwang ES, Fowble B. Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure. Plast Reconstr Surg. 2012;130(3):503–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ. Optimizing the total skin-sparing mastectomy. Arch Surg. Feb 2008;143(1):38–45- discussion 45.PubMedCrossRefGoogle Scholar
  11. 11.
    Fowble BL, Einck JP, Kim DN, et al. Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer. Int J Radiat Oncol Biol Phys. 2012;83(2):494–503.PubMedGoogle Scholar
  12. 12.
    Peled AW, Foster RD, Garwood ER, et al. The effects of acellular dermal matrix in expander-implant breast reconstruction after total skin-sparing mastectomy: results of a prospective practice improvement study. Plast Reconstr Surg. 2012;129(6):901e–8e.PubMedCrossRefGoogle Scholar
  13. 13.
    Ward J, Cohen IK, Knaysi GA, Brown PW. Immediate breast reconstruction with tissue expansion. Plast Reconstr Surg. 1987;80(4):559–66.PubMedCrossRefGoogle Scholar
  14. 14.
    Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20(10):3218–22.PubMedCrossRefGoogle Scholar
  15. 15.
    Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg. 2013;132(5):1043–54.PubMedCrossRefGoogle Scholar
  16. 16.
    Sacchini V, Pinotti JA, Barros AC, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203(5):704–14.PubMedCrossRefGoogle Scholar
  17. 17.
    Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg. 2003;238(1):120–7.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128:1005–14.PubMedCrossRefGoogle Scholar
  19. 19.
    Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34(2):143–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212(4):686–93; discussion 693–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Tokin C, Weiss A, Wang-Rodriguez J, Blair SL. Oncologic safety of skin-sparing and nipple-sparing mastectomy: a discussion and review of the literature. Int J Surg Oncol. 2012;2012:921821.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Esserman LJ, Alvarado MD, Howe RJ, et al. Application of a decision analytic framework for adoption of clinical trial results: are the data regarding TARGIT-A IORT ready for prime time? Breast Cancer Res Treat. 2014;144(2):371–8.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Wickberg A, Holmberg L, Adami HO, Magnuson A, Villman K, Liljegren G. Sector resection with or without postoperative radiotherapy for stage I breast cancer: 20-year results of a randomized trial. J Clin Oncol. 2014;32(8):791–7.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Frederick Wang
    • 1
  • Anne Warren Peled
    • 1
  • Elisabeth Garwood
    • 4
  • Allison Stover Fiscalini
    • 2
  • Hani Sbitany
    • 1
  • Robert D. Foster
    • 1
  • Michael Alvarado
    • 2
  • Cheryl Ewing
    • 2
  • E. Shelley Hwang
    • 3
  • Laura J. Esserman
    • 5
    Email author
  1. 1.Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Carol Franc Buck Breast Care Center, Department of SurgeryUniversity of California, San FranciscoSan FranciscoUSA
  3. 3.Department of SurgeryDuke University Medical CenterDurhamUSA
  4. 4.Department of Radiology and Biomedical ImagingUniversity of California, San FranciscoSan FranciscoUSA
  5. 5.Carol Franc Buck Breast Care CenterUniversity of California, San FranciscoSan FranciscoUSA

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