This patient is undergoing bilateral skin-sparing mastectomy for breast cancer reconstruction. She desires a smaller, less tautic reconstruction. So we've marked the inframammary fold from here to here. We've marked the meridian of the breast along the inframammary fold and on the upper pole. We've marked the anticipated location for the nipple reconstruction. The two vertical components were marked with her in the standing position so that when the breast is moved from side to side, these marks line up with this inferior vertical mark. The limbs on this patient are 8 centimeters long, so this can be adjusted up and down based on the size of the patient's breast. This black line indicates the incisions that the breast surgeon will use. They'll also make an incision here. We will not make an inframammary incision, as this lower breast skin will be deepthelialized. This triangle up here represents the skin that will be removed during the skin-sparing mastectomy. Oftentimes, we will leave a dart of skin here in case we are concerned about blood flow to the corners of the mastectomy flaps. We will start with deepthelialization, if possible, prior to the mastectomy. We typically deepthelialize with scissors, which can be assisted by scoring of the skin. So here, the deepthelialization has been completed, and the case is turned over to the breast surgeon. Here the mastectomy has been completed. We have two superior quadrants that come together at the inframammary fold and a deepthelialized flap inferiorly. Next, we will take a 6-by-3-inch piece of woven vicral mesh and suture it along the edge of the inferior mastectomy flap. Next, we will take a tissue expander that has been temporarily filled with air, and we will suture it down to the chest wall. Here we have sutured down the medial, superior, and inferior tabs of the expander. Next, we will back cut about 4 cm of the inferior mastectomy flap. The free edge of the vicral mesh is then sutured to the chest wall along the top and side of the expander. We will often tack the lateral mastectomy flap down to the chest wall in order to better contour the lateral reconstruction, and also to limit lateral migration of the expander. At this point, we will deflate the tissue expander and refill it with saline to a volume that fits comfortably. Our expander is in place and refilled with saline. A drain is placed, and now we will begin the closure. The closure will feel relatively snug. We have left the triangular dart here in case we were concerned about blood flow to the mastectomy flap corners. In this case, it was removed. Here we can see the completed reconstruction on the table. And here is an example of a patient who underwent this procedure.

bilateral mastectomy

breast reconstruction

tissue expander

skin-sparing

surgical markings