BREAST

Skin-Reducing Mastectomy
Maurizio B. Nava, M.D.
Background: The authors propose a combined flap technique to reconstruct
Umberto Cortinovis, M.D. large and medium-sized ptotic breasts in a single-stage operation by use of
Joseph Ottolenghi, M.D. anatomical permanent implants.
Egidio Riggio, M.D. Methods: The authors enrolled 28 patients fulfilling criteria for skin-sparing
Angela Pennati, M.D. mastectomy and presenting with ptotic breasts whose areola-to-inframammary
Giuseppe Catanuto, M.D. fold distance was more than 8 cm. All reconstructions were performed as a
Marco Greco, M.D. single-stage procedure. After preoperative planning, a large area in the lower
Guidubaldo Querci della half of the breast was deepithelialized according to the conventional Wise
Rovere, M.D. pattern. Mastectomy was then carried out. To perform reconstructions, the
Milan, Italy; and London, United inferomedial fibers of the pectoralis major muscle were dissected and sutured
Kingdom to the superior border of the inferior dermal flap. An anatomical implant was
then inserted into the pouch, which was closed laterally with the previously
harvested serratus anterior fascia. Skin flaps were finally closed down to the
inframammary fold.
Results: The authors performed 30 procedures on 28 patients. The medium
size anatomical implants was 433 cc. Twelve women achieved symmetrization
in a single stage ending in a symmetric inverted-T scar. The overall com-
plication rate was 20 percent, with four cases (13 percent) complicated by
severe, extensive necrosis of the skin flaps requiring implant removal.
Conclusions: Breast cancer treatment must nowadays optimize cosmetic
results. This can be accomplished in selected cases by means of a single-stage
operation that the authors call “skin-reducing mastectomy.” The final scars
imitate those of cosmetic surgery. Careful patient selection and improvement
in the learning curve may reduce the complication rate. (Plast. Reconstr.
Surg. 118: 603, 2006.)

S
kin-sparing mastectomy was introduced
into clinical practice several years ago and
is now considered an oncologically safe sur-
gical procedure.1–5 Saving the skin envelope and
inframammary fold improves the reconstructive
outcome of a conventional radical modified or
simple mastectomy and avoids unpleasant scar-
ring.
Carlson and colleagues6 classified skin-sparing
mastectomy into four categories based on type of
incision used and amount of skin removed.
Types I, II, and III of this classification involve
mainly small breasts and take into consideration
the position of a previous biopsy scar. In all of
these cases, mastectomy is carried out through a
periareolar approach. Type IV skin-sparing mas-
tectomy involves large ptotic breasts that require
From the Plastic and Reconstructive Surgery and Breast
Units, Istituto Nazionale Tumori, and the Breast Unit,
Royal Marsden Hospital, National Health Service.
Received for publication March 26, 2005; accepted May 26,
2005.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000233024.08392.14
a conspicuous reduction of the skin envelope
and a contralateral mastopexy or reduction.
Reconstruction surgery in this subset of mastec-
tomies can be performed by means of totally sub-
muscular expanders or permanent prostheses
rather than autologous flaps. Final scarring is sim-
ilar to that from cosmetic surgery (inverted T).
This technique has two main limitations. First,
the two long superior flaps that close down to the
inframammary fold may become ischemic, be-
cause of their length and thinness. This could re-
sult in healing complications of the inverted-T scar,
such as superficial epidermolysis, wound dehis-
cence, and implant exposure.7 Second, a perma-
nent prosthesis in the lower pole of the recon-
structed breast lacks projection, resulting in
excessive upper pole fullness. This inconvenience
can be overcome in part by means of a two-step
operation initially using tissue expansion.
In this study, we describe an alternative tech-
nique to minimize complications and poor cos-
metic results in a single-step operation using ana-
tomical silicone gel implants and a dermal-muscle
flap pocket.

www.PRSJournal.com 603
 Plastic and Reconstructive Surgery • September 1, 2006
PATIENTS AND METHODS
We enrolled 28 patients on behalf of Istituto
Nazionale Tumori, in Milan, Italy, from Septem-
ber of 2001 to October of 2004. All patients ful-
filled the oncological criteria for skin-sparing mas-
tectomy.
We submitted all patients to reconstructive cri-
teria and included all women who presented with
sagging breasts and an areola-to-inframammary
fold distance of more than 8 cm and a nipple-to-
areola distance of more than 25 cm in the trial for
this technique.
Operations were performed by a team made
up of a surgical oncologist and a plastic surgeon.
All reconstructions were performed as a single-
stage procedure. We used McGhan style 410/510
highly cohesive silicone gel anatomical perma-
nent implants (Inamed, a Division of Allergan
Inc., Irvine, Calif.), with full and extra-full projec-
tion. Cosmetic and reconstructive results were as-
sessed by plastic surgeons comparing preoperative
and postoperative photographs.
All data were collected retrospectively from
the clinical medical data records.
Surgical Technique
The Preoperative Project
As with all surgical procedures we perform
for breast reconstruction or reshaping after
wide local excision, our strategy begins with a
careful preoperative assessment. With the pa-
tient standing in front of us, we first mark the
position of the new nipple along the midcla-
vicular line at a distance between 19 and 23 cm.
The marking then follows the steps used for a
normal breast reduction or mastopexy using a
conventional Wise pattern; however, on the mas-
tectomy side, we erase the semicircular drawing
representing the position of the new nipple-
areola complex and we prolong the two vertical
limbs up to the new nipple position. The length
of the two limbs on this side depends on the
degree of reduction we want to achieve and is
usually between 5 and 7 cm, plus the 2 cm radius
of the nipple-areola complex. The distal ends of
the two limbs are then extended medially and
laterally with patient lying in the supine posi-
tion, so as to intercept the previously marked
inframammary fold (Figs. 1 and 2, above, left).
Surgical Procedure
Skin is incised full thickness along the vertical
limbs of the reduction pattern, including only the
epidermis (partial thickness) after the inframam-
mary line. A dermal flap is then created by deepi-
604
Fig. 1. Preoperative markings for skin-reducing mastectomy on
the left breast and mastopexy on the right breast.
thelialization of a large lower area of skin between
the inframammary line and the medial and lateral
extensions of the reduction pattern.
Before the mastectomy is started, the lower
flap is sculpted down to the inframammary fold,
whose anatomy we always identify to allow care-
ful preservation. The gland has to be removed
with accurate sparing of the superior flap’s sub-
dermal vascularization. We always tend to dissect
following Cooper’s ligaments plane, to mini-
mize ischemia without compromising oncologic
safety and complete removal of breast tissue.
This access usually allows for easy axillary dis-
section or sentinel node identification and biopsy.
After the oncologic procedures are completed, we
start the reconstruction by incising along the lat-
eral border of pectoralis major. The inferior and
lower-medial insertions of this muscle are divided
and sutured to the superior border of the dermal
flap (Fig. 2, above, right). A large pouch is then
created to accommodate an anatomically shaped
permanent prosthesis. The pouch is then closed
laterally with the previously raised serratus muscle
(Fig. 2, below, left). Before the pouch is closed, a
suction drain is placed inside it. Once the viability
of the cutaneous flaps has been carefully assessed,
the skin is sutured by approximating the distal end
of the two vertical limbs to the inframammary line.
The nipple is usually reconstructed in a sec-
ond step with the patient under local anesthesia.
In selected cases, nipple autotransplantation can
be performed, even if it remains unclear whether
the superior flap can provide adequate vascular-
ization to the skin graft. In a few cases, we recon-
structed the nipple intraoperatively with local skin
Volume 118, Number 3 • Skin-Reducing Mastectomy
Fig. 2. (Above, left) Preoperative markings for right skin-reducing mastectomy. (Above, right) The lower border of the pectoralis major
muscle is sutured to the inferior dermal flap. (Below, left) The serratus fascia is raised to close the pouch laterally. (Below, right) Post-
operative result.
flaps (Fig. 2, below, right). There is still concern
regarding the oncologic safety of nipple preser-
vation in cancer patients.7 In this case, we normally
perform frozen section analysis of retroareolar
breast ducts.
RESULTS
We performed 30 procedures in 28 patients.
The median patient age was 47 years (range, 33 to
67 years). There was a median follow-up of 13.6
months. Six patients (21.4 percent) were smokers.
We subdivided patients into groups according
to the stage of disease: five patients (17.9 percent)
had Tis, one patient (3.6 percent) had Tis(Paget), 13
patients (46.4 percent) had T1N0, one patient had
T1N1 with associated extensive ductal carcinoma
in situ not suitable for conservation, one patient
had T2N0, and two patients (7.14 percent) had
T2N1 disease. One patient presented with bilat-
eral breast cancer (T1N1 on one side and T2N1
contralaterally).
A single patient was at high risk because of
gene mutations and had undergone a bilateral
prophylactic mastectomy, and two patients (7.14
percent), after breast cancer on one side, decided
to undergo contralateral prophylactic mastectomy
(Fig. 3). We used this technique for a case of
benign extensive disease (chronic breast abscess).
In seven patients (25 percent), we performed
axillary dissection; six dissections were performed
through a mastectomy incision and one dissection
required a separated incision in the axilla. We
identified and excised 15 sentinel nodes (50 per-
cent). In no case did we need a new lateral inci-
sion.
One patient had bilateral mastectomy for bi-
lateral invasive breast cancer. For reconstruction,
style 410/510 anatomically shaped, highly cohe-
sive silicone gel implants were used; the medium
605
 Plastic and Reconstructive Surgery • September 1, 2006
Fig. 3. Prophylactic skin-reducing mastectomy was performed
on the left breast due to gene mutation. The patient underwent
a two-stage reconstruction on the right breast (above, preoper-
ative view; below, 16-month postoperative view).
size implant was 433 cc, the largest implant was 620
cc, and the smallest was 195 cc.
We performed 12 contralateral symmetriza-
tion procedures (40 percent) in one stage. In
seven cases, we performed an inferior pedicle
breast reduction, and in five cases we performed
a mastopexy.
Three patients had one-stage nipple recon-
struction in the operating room, one with by local
skin flaps and two with nipple-areola skin grafts
(one bilaterally). Second-stage nipple reconstruc-
tion was performed in six cases 6 months after
implant allocation.
Six patients developed superficial epidermol-
ysis initially treated conservatively by regular dress-
ing. Four patients required implant removal be-
cause of exposure after necrosis of the superior
flaps. Three of these patients were smokers. After
complete healing of the wound, a new reconstruc-
tion was carried out with tissue expansion in all the
606
cases. None of the uncomplicated cases reported
capsular contracture (Baker I, 78 percent; Baker
II, 28 percent) All patients who had invasive can-
cer received adjuvant chemotherapy. No patient
received postoperative radiation therapy to the
chest wall, internal mammary chain, or supracla-
vicular fossa.
DISCUSSION
In 1991, Toth and Lappert introduced,7 for
the first time, the idea of preoperative plastic sur-
gery planning and skin-saving techniques in pa-
tients undergoing simple or radical modified mas-
tectomies. The oncological safety of this
procedure has recently been demonstrated in sev-
eral studies, and skin-sparing mastectomy is the
technique of choice in some patients.1–5 Small-
breasted women can be reconstructed using per-
manent prostheses or temporary expanders. In
these cases, the breast can be easily removed
through a periareolar approach.
Large or medium-sized breasts are usually
ptotic and require a variable degree of skin re-
duction and a contralateral symmetrization for an
acceptable cosmetic and reconstructive outcome.
This is normally accomplished by removing a
larger island of skin, including the nipple-areola
complex, thereby creating the usual submuscular
pocket filled with a temporary expander. A second
operation is then necessary to reach the final re-
constructive result, and it is not really possible to
carefully predict the result from the initial mas-
tectomy. Scarring in this case is particularly un-
pleasant and asymmetric when contralateral
breast symmetrization is carried out.
Mastectomies in large breasts using the plastic
surgery techniques described by Toth and
Lappert7 could, in theory, achieve a rewarding
outcome. However, several difficulties need to be
overcome.
One limitation is related to the relative lack of
space in the inferior and medial aspects of the
submuscular pocket. It is possible to release the
inferior fibers of the pectoralis major, but in this
case, a subcutaneous implant could easily become
exposed, especially when it is put underneath the
long and possibly ischemic superior mastectomy
flap. This length, as Toth and Lappert7 themselves
describe, is critical in determining severe compli-
cations not rare if the oncologist during dissection
needs to leave very thin poorly vascularized flaps.
Many authors have tried to overcome necro-
sis and poor results using a modified Wise
pattern8 rather than a subcutaneous pouch.9 A
muscle-skin combined pocket for permanent
Volume 118, Number 3 • Skin-Reducing Mastectomy
implant allocation was described for prophylac-
tic and cosmetic purposes by Bostwick in the
early 1990s.10 At that time, there was no infor-
mation on the possibility of saving skin during
oncologic procedures. In the technique, a
pouch made up of pectoralis major and serratus
anterior is closed anteriorly by the lower dermal
flap deepithelialized before starting mastec-
tomy. This allows room for the lower aspects of
the reconstruction and protects the implant by
means of a two-layer cover. The nipple-areola
complex is subsequently grafted in the new po-
sition at the top of the inverted T.
Hammond et al.11 introduced Bostwick’s idea
in breast cancer treatment. They modified the
original technique using temporary expanders in
the large majority of the cases presented, mandat-
ing a second operation for permanent implant
insertion. We decided to follow Bostwick’s original
technique in our study, and that allowed us to
obtain a cosmetically satisfying reconstruction in a
single-step operation.
Use of an anatomical prosthesis when allocated
under a wide dermal-muscle flap pocket gives an
immediate final aspect to the reconstructed breast.
Careful saving of the inframammary fold allowed us
to obtain an immediate natural ptosis.12 In our in-
stitution, mastectomies are conventionally accom-
plished by preserving the serratus and pectoralis
major fascia. If a patient is scheduled to undergo a
skin-sparing mastectomy, she should not have chest
wall infiltration diagnosed preoperatively. However,
if intraoperatively, for oncological safety, wider ex-
cision of fascia is required, we suggest either leaving
the pouch open in the lateral aspect or closing it
with serratus fibers carefully elevated together with
the pectoralis major. An alternative option could be
offered by human acellular tissue matrix
implantation.13 This is a rather new skill in breast
reconstruction, and we are waiting for further vali-
dation from clinical studies before introducing it
into current clinical practice.
By using the combined pouch, we had the
chance to allocate large mammary implants (me-
dium volume, 433 cc). The large superior access has
given us the possibility of identifying sentinel lymph
nodes in all cases and avoiding a second scar in the
armpit. Even axillary dissection in the large majority
of cases (85 percent) can be performed through this
access. Regardless, it is advisable to avoid strong re-
traction to prevent flap problems while exposing the
anatomical structures.
The aesthetic purpose of this operation is op-
timized by contralateral symmetrization (Fig. 4).
In view of this, we decided to extend the indica-
tions of type IV mastectomy to all patients requir-
ing a cosmetic procedure with an inverted-T scar
on the contralateral breast (Table 1). An 8-cm
distance between the areola and inframammary
fold has been considered the minimum length
needed to create a viable dermal flap and a pocket
large enough to accommodate a prosthesis. In all
other cases, skin-sparing mastectomy can be better
carried out using a periareolar approach. Symme-
trization could be easily planned for the same
operation. However, we gave all of our patients the
choice of having surgery or not on the healthy
breast and therefore the chance of a second op-
eration whenever they felt it was appropriate. Con-
tralateral immediate reduction/mastopexy was
performed in 11 patients. The inferior pedicle
technique seems to be the most suitable when a
reduction is needed, whereas for mastopexy we
prefer a superior pedicle technique, folding the
deepithelialized inferior pole of the breast into
the retroareolar space as an “auto-prosthesis.”
The nipple-areola complex was usually recon-
structed in local anesthesia as a day case proce-
dure. We preserved and subsequently grafted the
nipple-areola complex in only two patients who
had special concerns regarding cosmesis. Both
were cancer patients, so we performed a frozen
section before grafting. The results showed no
cancerous tissue in the retroareolar ducts. One
patient had a bilateral mastectomy, but because of
a heavy smoking addiction, one graft totally failed
and the other survived only partially. The second
grafted patient had no complications.
In many series describing inverted-T mastec-
tomies, a high complication rate is reported (up to
27 percent), especially at the T junction6,9,11,14 (Ta-
ble 2). Toth and Lappert, in the earliest article
regarding skin-sparing mastectomies, reported
skin problems in four cases of inverted-T proce-
dures reconstructed with transverse rectus abdo-
minis musculocutaneous flaps.7 Carlson et al., in
their 1997 series, indicated a 27 percent compli-
cation rate for type IV mastectomy.6 All patients
were presumably treated with autologous flap re-
construction. Further observation from Carlson
on an enlarged population confirmed the previ-
ously reported percentage (26.5 percent).14 A
higher failed reconstruction rate is to be expected
in an implant-based technique. Hammond et al.11
and Hudson and Skoll9 reconstructed the breast
mound after inverted-T procedures by using either
temporary expanders in a two-stage operation or per-
manent subcutaneous prostheses. Hammond et al. de-
scribed two out of 19 reconstructions with complica-
tions, with one case progressing to implant extrusion.
607
 Plastic and Reconstructive Surgery • September 1, 2006

Fig. 4. Oncologic and cosmetic treatment performed during the same operation. (Above) Preoperative views. (Below) Postoperative
views.

Table 1. Skin-Reducing Mastectomy: Oncologic and Reconstructive Criteria

Oncologic Criteria
• Invasive carcinoma unsuitable for breast conservation
• Multicentric carcinoma with no evidence of skin
involvement
• Paget’s disease of the nipple associated with either in
situ or invasive carcinoma in peripheral location
• Extensive ductal carcinoma in situ
• Prophylactic mastectomy
• Post neoadjuvant chemotherapy in which conservation
is still not indicated
Reconstructive Criteria
• Medium-sized or large ptotic breasts
• Nipple-sternal notch distance ⬎25 cm
• Areola-inframammary fold distance ⬎8 cm
• To be avoided in smokers and patients with microvascular
problems (previous radiotherapy, diabetes)

Hudson and Skoll, allocating implants subcutaneously,
reported extrusion in three cases. They provide a thor-
ough description of the complicated cases, and all were
related to compromised peripheral microcirculation
in heavy smokers or diabetics. With our technique, we
observed a 13 percent rate of severe complications
requiring implant removal and an overall complication
rate of 20 percent (skin problems). Complications in
our study began with superficial epidermolysis or mi-
nor wound dehiscence. One-third resolved with con-
servative treatment, while the other two-thirds pro-
gressed to necrosis and implant exposure. As expected,
catecholamine released due to the effects of nicotine
damaged the vascularity of thin and long skin flaps.15
Carlson et al. correlated tobacco smoking with a sig-
nificantly higher rate of necrosis in a subset of smokers
who underwent skin-sparing mastectomy (49 percent
versus 19 percent in the nonsmoking group, p ⬍

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Volume 118, Number 3 • Skin-Reducing Mastectomy

Table 2. Inverted-T Mastectomy Reconstructive Technique and Complication Rate

Authors (ref.) No. of Type of Total No. Minor Implant
Cases Reconstruction of Complications Complications Extrusion
Toth and Lappert, 19917 –* TRAM flaps 4* 4* (superficial –
epidermolysis)
Carlson et al., 19976 44 Not reported, presumably TRAM flaps 12/44 (27%) – –
Hammond et al., 200211 12 Two-stage implant reconstruction 2/12 (16.6%) 1/12 (8.3%) 1/12 (8.3%)
Hudson and Skoll, 20029 19 Single-stage implant reconstruction 3/19 (15.7%) Not reported 3/19 (15.7%)
Carlson, 200414 68 Not reported, presumably TRAM flaps 18 (26.5%) – –
*Number of Wise pattern mastectomies was not specified. All complicated cases were inverted-T mastectomies.

0.001).6 In our series, 75 percent of the implants re-
moved were from patients who smoked more than 20
cigarettes per day. Some authors suggested intraoper-
ative assessment of skin viability with fluorescein to
prevent ischemia.11 We, in accordance with Carlson et
al., did not find this device to be helpful, relying only
on clinical observation of skin flap color and red bleed-
ing from the edges.14
In view of our report, we advise surgeons to
avoid using the described technique in heavy
smokers and whenever microvascular disease
(e.g., diabetes, postradiation therapy, and so on)
is present. In our opinion, the complication rate
can be lowered by accurate patient selection and
improving the learning curve of the technique.
Although the latissimus dorsi flap plays a ma-
jor role in repairing failed reconstructions caused
by extensive skin necrosis, we never used it as a
salvage flap. In all our complicated cases, skin flaps
were still large enough to allow expander alloca-
tion and a conventional two-stage procedure.
Whenever it was not strictly required, we tended to
preserve large myocutaneous flaps to reduce bio-
mechanical sequelae16 and to keep them available
for further reconstructions.
A possible option to reduce risks and optimize
cosmetic results could consist of using a vertical
approach to mastectomy, with a limited skin take-
out followed by a periareolar and vertical skin
closure.14 This is an interesting access to be even-
tually endorsed in preoperative plastic surgery
planning for mastectomy. In our opinion, how-
ever, it does not seem to be appropriate in very
large and ptotic glands (Fig. 4). We would con-
sider it for medium-sized ptotic breasts and even
to produce symmetrical scars. The decision in
these cases always has to be left to the patient, with
the surgeon possibly offering the patient the
chance to undergo a two-stage procedure with
contralateral augmentation. This strategy, accord-
ing to our experience, produces extremely satis-
fying cosmetic results.
Capsular contracture is one of the main issues
in implant reconstructions affecting the final ap-
pearance of the new breast. Final results were
judged by plastic surgeons and patients as ex-
tremely satisfying, especially with regard to the
optimal degree of ptosis and appropriate distri-
bution of volume between the superior and infe-
rior and medial and lateral aspects of the breast.
All of our patients were rated as having Baker
grade I or II contracture (median follow-up, 13.6
months). In our opinion, complete release of the
inferomedial pectoralis major fibers and the in-
ferior dual dermal-adipose plane allowed for a
very soft and natural reconstruction.
CONCLUSIONS
Oncologic procedures in breast cancer nowa-
days must consider accurate preoperative assess-
ment to optimize cosmetic results. Large or me-
dium-sized breast cosmesis often requires a certain
degree of skin envelope reduction. This can be
accomplished in eligible cases by means of a sin-
gle-step operation that we call a “skin-reducing
mastectomy.” On the basis of this study, we are
going to offer all of our patients who meet appro-
priate oncologic and reconstructive criteria this
kind of treatment.
Our goal will be to assess accurately in a large
series the complication rate and cosmetic results.
We believe that once the safety of this technique
has been successfully achieved and demonstrated,
it can be adopted extensively. The majority of
women who need a mastectomy usually present
with an excessive skin envelope. All of them can be
offered a skin-reducing mastectomy, and by means
of a single operation, we might be able to mini-
mize unpleasant scarring and offer a favorable
cosmetic and psychological outcome.
Maurizio B. Nava, M.D.
Plastic and Reconstructive Surgery Unit
Istituto Nazionale Tumori
Via G. Venezian 1
20133, Milan, Italy
nava@istitutotumori.mi.it

609
 Plastic and Reconstructive Surgery • September 1, 2006
REFERENCES
1. Kroll, S. S., Khoo, A., Singletary, S. E., et al. Local recurrence
risk after skin-sparing and conventional mastectomy: A 6-year
follow-up. Plast. Reconstr. Surg. 104: 421, 1999.
2. Slavin, S. A., Schnitt, S. J., Goldwyn, R. M., et al. Skin-sparing
mastectomy and immediate reconstruction: Oncologic risks
and aesthetic results in patients with early-stage breast can-
cer. Plast. Reconstr. Surg. 102: 49, 1998.
3. Rivadeneira, D. E., Simmons, R. M., Osborne, M. P., et al.
Skin-sparing mastectomy with immediate breast reconstruc-
tion: A critical analysis of local recurrence. Cancer J. 6: 331, 2000.
4. Simmons, R. M., Fish, S. K., Osborne, M. P., et al. Local and
distant recurrence rates in skin-sparing mastectomies com-
pared with non-skin-sparing mastectomies. Ann. Surg. Oncol.
6: 676, 1999.
5. Medina-Franco, H., Vasconez, L. O., Urist, M. M., et al. Fac-
tors associated with local recurrence after skin-sparing mas-
tectomy and immediate breast reconstruction for invasive
breast cancer. Ann. Surg. 235: 814, 2002.
6. Carlson, G. W., Bostwick, J., III, Wood, W. C., et al. Skin-
sparing mastectomy: Oncologic and reconstructive consid-
erations. Ann. Surg. 225: 570, 1997.
7. Toth, B. A., and Lappert, P. Modified skin incisions for
mastectomy: The need for plastic surgical input in preoper-
ative planning. Plast. Reconstr. Surg. 87: 1048, 1991.
8. Skoll, P. J., and Hudson, D. A. Skin-sparing mastectomy using
a modified Wise pattern. Plast. Reconstr. Surg. 110: 214, 2002.
610
9. Hudson, P. A., and Skoll, P. J. Complete one stage, imme-
diate breast reconstructions with prosthetic material in pa-
tients with large or ptotic breasts. Plast. Reconstr. Surg. 110:
487, 2002.
10. Bostwick, J. Total mastectomy with breast skin and volume
reduction using an inverted t incision. In Plastic and Recon-
structive Breast Surgery. Vol. II. St. Louis, Mo.: Quality Medical
Publishing, 1990. Pp. 1048 –1054.
11. Hammond, D. C., Capraro, P. A., Arnold, J. F., et al. Use of
a skin-sparing reduction pattern to create a combination
skin-muscle flap pocket in immediate breast reconstruction.
Plast. Reconstr. Surg. 110: 206, 2002.
12. Nava, M., Quattrone, P., Riggio, E., et al. Focus on the breast
fascial system: A new approach for inframammary fold re-
construction. Plast. Reconstr. Surg. 102: 1034, 1998.
13. Baxter, R. Intracapsular allogenic dermal grafts for breast
implant-related problems. Plast. Reconstr. Surg. 112: 1692,
2003.
14. Carlson, G. W. Trends in autologous breast reconstruction.
Semin. Plast. Surg. 18: 79, 2004.
15. Chang, L. D., Buncke, G., Buncke, H., et al. Cigarette, smok-
ing, plastic surgery, and microsurgery. J. Reconstr. Microsurg.
3: 290, 1996.
16. Martino, G., Nava, M., Benson, J., et al. Breast reconstruction
with myocutaneous flaps: Biomechanical aspects. In Onco-
plastic and Reconstructive Surgery of the Breast. London: Taylor
& Francis, 2004. Pp. 141–149.