How to do minimal scar mastectomy: first‐reported novel concept of nipple sparing mastectomy without reconstruction

Distinctive to nipple sparing mastectomy, immediate reconstruction is mandatory. Minimal scar mastectomy (MSM) is a novel concept of nipple sparing mastectomy without reconstruction, not previously reported. MSM was performed using round block technique. The most important step in MSM is to determine the redundant skin envelope, which will occur in nipple sparing mastectomy without reconstruction. The redundant skin was approximated and marked around the nipple areolar complex (NAC) using an approximation method, quite similar to that used in the drawing of the skin ellipse for a mastectomy. The superior margin of the outer ring of round block technique was obtained by displacing the breast inferiorly until the superior breast skin envelope was firmly stretched, then marking out on the stretched breast skin the position of the original superior edge of the areola when the breast was not displaced (Video S1). The above step was then repeated to obtain the inferior, medial and lateral margins of the outer ring by pulling the breast superiorly, laterally and medially, respectively. The four markings were then joined to form an outer ring. The boundaries of the mastectomy were marked out (Fig. S1). The skin between the outer ring and NAC was de-epithelized. This de-epithelized area was then divided along half its circumference (Fig. S2), raising the NAC as a full-thickness skin flap supported on a superior-medial pedicle (Video S2). Maximum breast tissue was removed from beneath NAC using sharp scissors dissection. Mastectomy was then performed via the incision at the deepithelized area, conserving the skin envelope and NAC (Video S3). A drain was placed before the outer ring of the round block was purse-stringed using a permanent 2/0 suture, to achieve a diameter similar to the contralateral NAC (Video S4). The NAC was first anchored at the four corners and the wound closed in two layers. The sentinel lymph node biopsy or axillary clearance was carried out via a separate incision in the axilla. Reconstruction post-nipple sparing mastectomy will undoubtedly produce the best cosmetic outcome and should remain the standard of treatment. However, in selected small breasted patients with minimal ptosis, who desire to conserve NAC but do not want to have reconstruction post mastectomy, MSM can be an alternative to avoid an unsightly transverse mastectomy scar. This technique would be extremely useful in the Asian women in whom the breast size is relatively smaller and the rate of mastectomy without immediate reconstruction for early breast cancer was high at 81.7%. The benefits of MSM were many. First, conservation of NAC can improve the patients’ overall psychological well-being and avoid the need for nipple reconstruction. Second, the scar was concealed around the NAC (Fig. 1), giving a cosmetically more pleasing outcome as opposed to the transverse mastectomy scar (Fig. S3). Finally, should the patient wish to reconstruct later, the post reconstruction appearance would be better compared to reconstruction in a patient with a traditional mastectomy since the transverse scar was avoided. Potential complications include areolar widening and NAC necrosis. These complications can be avoided by using a permanent 2/0 suture and proper pre-operative patient selection with careful intra-operative tissue handling, respectively. Dogear formation may hypothetically arise if there is too much redundant skin to remove via round block technique. In conclusion, MSM is feasible in women with small breasts with minimal ptosis and can promise a better cosmetic outcome compared to radical modified mastectomy. MSM could potentially change the way mastectomy was performed in this selected group of patients.