Incidence of the superficial fascia and its relevance in skin‐sparing mastectomy

Abstract

BACKGROUNDWith the move away from classical radical mastectomy to ever more skin‐sparing procedures, there has been an ongoing discussion about how much skin and subcutaneous tissue should be resected to perform an adequate mastectomy while leaving viable skin flaps. One of the common recommendations is to dissect just superficial to the superficial layer (SL) of the superficial fascia of the breast. This, in turn, has revived the old, unsolved controversy about the existence or absence of the SL, a fascia that reportedly encloses the mammary gland ventrally. In skin‐sparing mastectomies (SSM), which combine tumor resection with immediate breast reconstruction, the ideal would be to create skin flaps that are thin enough to remove all breast tissue but at the same time are thick enough to preserve flap circulation. The feasibility of meeting these two goals simultaneously and the possible role and relevance of the SL as a guide to dissection in SSM was examined in this study.METHODSSixty‐two breast resection specimens from 31 women who underwent breast reduction were examined histologically to determine whether the SL was present, whether breast tissue could be detected within or beyond this SL, the measured distance between the caudal border of the dermis and the SL or the breast tissue, and whether the thickness of the subcutaneous fat layer was correlated with the patients' physical data, such as body weight or body mass index (BMI).RESULTSThe SL was absent in 44% of resection specimens. When the SL was present, 42% of specimens contained several islands of breast tissue within the SL. No breast tissue was found beyond the SL. The minimal distance between the SL and the dermis varied from 0.2 mm to 4.0 mm; the minimal distance between the breast tissue and the dermis was 0.4 mm. In 50% of specimens, the minimal distance between the dermis and the SL or breast tissue was < 1.1 mm. A distance of ≥ 5 mm was encountered in only 17% of specimens, and a distance of ≥ 10 mm was encountered in only 5% of specimens. No significant correlation between the right and left breast was found with any of the parameters examined. A weak negative correlation was seen between the BMI and the mean thickness of the subcutaneous fat (P = 0.049; correlation coefficient [r] = −0.39; Spearman rank correlation).CONCLUSIONSHistologic evaluation revealed that the SL is not present in all breasts and, thus, cannot serve as a reliable plane of dissection. Furthermore, if the SL is present microscopically, then it often is too thin and delicate to be detectable macroscopically. Finally, even if the SL is present and visible macroscopically, the distance to the overlying skin is so small in the majority of patients that a dissection superficial to the SL would not leave viable skin flaps in skin‐sparing mastectomies. Cancer 2002;94:1619–25. © 2002 American Cancer Society.DOI 10.1002/cncr.10429

The Superficial Margin of the Skin-Sparing Mastectomy for Breast Carcinoma: Factors Predicting Involvement and Efficacy of Additional Margin Sampling

“…12 In order to achieve this goal, one of the common recommendations is to dissect just superficial to the superficial layer of the superficial fascia of the breast, because the superficial fascia encloses the mammary gland ventrally. 12 However, as many as 44% of breasts do not have a superficial fascial layer. Even when the superficial layer is present, 42% of them are irregular and contain islands of breast tissue within.…”

“…Even when the superficial layer is present, 42% of them are irregular and contain islands of breast tissue within. 12 The minimal distance between the superficial layer and the dermis varied from only 0.2 to 4.0 mm, which means that the superficial fascial layer is too superficial to use as a landmark for dissection since the resulting flap would be too thin. These findings provide an anatomic basis for the observed difficulty in removing all the breast tissue in SSM.…”

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

“…At the European institute of oncology (EIO), 72% of the new cancers receive breastpreserving surgery, and the remaining 28% mastectomy. A significant improvement has been achieved by the skinsparing mastectomy technique, as validated by several publications [2][3][4][5][6][7][8][9][10][11]. The preservation of the skin envelope enhances the quality of breast reconstruction, enabling the reconstructed breast to keep a more natural shape.…”

Systematic review of methodologies used to assess mastectomy flap viability

“…The challenge lies in complete removal of all breast tissue to ensure oncological safety, while leaving sufficient skin flap thickness to maintain skin viability5. The superficial plane of dissection between the subcutaneous fat and breast tissue has been found to be indistinct under microscopic examination in almost half of patients6, making it technically difficult, especially with the more limited field of view compared with that of conventional mastectomy. Immediate breast reconstruction is also associated with a significantly higher rate of complications (up to 50 per cent) compared with delayed procedures (up to 36 per cent)7.…”