mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold

Mastectomy flap design: the ‘waisted teardrop’ and a method to

reduce the lateral foldans_6046 329..333

Rebecca Thomas, Christine Mouat and Burton KingDepartment of General Surgery, Wellington Regional Hospital, Riddiford Street, Wellington, New Zealand

Key words

cosmesis, dog ear, lateral fold, mastectomy, surgicalheuristics.

Correspondence

Mr Burton King, Department of Surgery, WellingtonRegional Hospital, Riddiford Street, Wellington 6021,New Zealand. Email: [email protected]

B. King FRACS; C. Mouat FRACS; R. Thomas MBChB,BSc.

This paper is based on a presentation made at the NewZealand Association of General Surgeons AnnualMeeting in March 2010.

Accepted for publication 5 February 2012.

doi: 10.1111/j.1445-2197.2012.06046.x

Abstract

Background: There are various methods to design mastectomy flaps but few arestandardized. Lateral skin folds or ‘dog ears’ are a common, unsightly and uncom-fortable consequence following a surgery in overweight patients.Methods: We describe a simple technique for designing mastectomy flaps and amethod to eliminate the lateral dog ear.Conclusion: The design is easy to apply and may enable standardization. Heuristicsof mastectomy design should be standardized and included in surgical training.

Background

More than 1.3 million new cases of breast cancer are diagnosedworldwide each year, with more than 2500 new cases reported inNew Zealand alone.1 Up to half of all women diagnosed undergo amastectomy as their primary surgical procedure. An additionalgroup of patients goes on to completion mastectomy followingunfavourable pathology results after initial breast-conservingsurgery.

Redundant skin at the lateral edge of the mastectomy scar, theso-called dog ear, is common particularly in overweight or large-breasted patients. Although it can be considered ‘minor morbidity’,the dog ear is unsightly, can cause discomfort, irritation and caninterfere with wearing a brassiere or external prosthesis.

A number of techniques have been described to correct thisdefect. These include alternative design of the original incision –lengthening or a fish-tail incision. Separate excision of the redun-dant tissue, ‘scrunch’ or ‘skewed suturing’ has been proposed.Many surgeons excise the dog ear as an interval secondary surgicalprocedure.

Farrar and Fanning first described a modified Y closure for themastectomy wound in 1988.2 They advocated closing the medial

aspect of the wound initially, then advancing the lateral corner medi-ally and excising the resultant two skin flaps. The remaining woundwas closed in two parts, leaving a Y-shaped scar. Other variations ofa Y or ‘fish tail’ incision have been reported.3,4 Hussien et al.reported good results after evaluating this technique in 28 patientsand found that patients most likely to require a fish-tail plasty wereolder, obese and had large breasts.5 The Y-shaped or fish-tail plastyrequires additional incisions, and the superolateral segment of theincision has the potential to inhibit arm movement.

Some believe that flap length discrepancy is a key factor in thecreation of dog ears and advocate measuring the lengths of the edgeof the flaps to avoid length asymmetry between the sides of theellipse. Devalia et al. recommended extending the standard trans-verse ellipse laterally and upwards towards the axilla in order tobetter align the flap lengths.6

Mirza and colleagues developed the teardrop incision for mastec-tomy after noting that excising the dog ear tissue at surgery left ateardrop-shaped defect. The resultant scar is flat and seldom pro-duces a dog ear.7

We believe that the ideal mastectomy incision design should havea teardrop shape, but additional measures can improve this stillfurther. We attempt to standardize mastectomy design by describing

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© 2012 The AuthorsANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons ANZ J Surg 82 (2012) 329–333

a simple method of designing this teardrop shape and a novel onco-plastic technique for addressing the lateral dog ear. Teaching theresulting heuristics of mastectomy design can improve the learningcurve for surgical trainees.8

Methods

Our technique is made up of two aspects: the ‘waisted teardrop’design and de-epithelialized advancement of the lateral flap.Slimmer patients tend to only require the waisted teardrop, whereasfor larger patients, we add the advancement of the lateral flap.

At surgery, the location of the tumour within the breast is markedon the overlying skin (Fig. 1). The major axis of the breast base ellipseis established, and the vertices of the ellipse are marked medially andlaterally (Fig. 2). This axis can be adjusted parallel to the major axisto ensure that the tumour is well within the skin paddle. The breast isretracted caudally with the flat of the hand and the two points areconnected by a straight line (Fig. 3). This is repeated with the breast

retracted in a cephalad direction (Fig. 4). This retraction takes intoaccount the varying skin tensions across the chest wall and results ina lentiform or teardrop-shaped ellipse (Fig. 5).

The unique feature of our technique is then used. The medial endof the ellipse is retracted laterally with an index finger along the

Fig. 3. Retracting the breast caudally.

Fig. 4. Retracting the breast in a cephalad direction.

Fig. 5. Teardrop-shaped ellipse encapsulating skin overlying tumour.

Fig. 1. Location of breast tumour marked on overlying skin.

Fig. 2. Establishing the major axis of the breast base ellipse in order tomark the vertices.

330 Thomas et al.

© 2012 The AuthorsANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons

major axis. This results in waisting of the medial end of the markedellipse. The symmetry of the ellipse is then reconstituted and marked(Fig. 6). This is then repeated at the lateral end of the teardrop wherethe skin is retracted (Fig. 7). The resultant teardrop often has a‘waisted’ appearance, with a narrow waist section in the middle(Fig. 8). The outermost markings are then used to guide the skinincision. This skin paddle represents the maximum amount of skinthat can be removed.

At completion of the mastectomy and any accompanying axillaryprocedure (Fig. 9), the closure is evaluated by temporarily opposingthe skin edges. If the patient has a slim or average build, the woundis closed directly in a standard manner. The resultant mastectomyscar will be a straight line or have some lateral upward obliquity(Fig. 10). If the patient has a large body habitus with an excesslateral fold (Fig. 11), the second part of our technique is brought intoplay.

Fig. 8. Waisted teardrop marked for incision.

Fig. 9. After mastectomy and any accompanying axillary procedure.

Fig. 10. Closure of mastectomy wound in a patient of slim or averagebody habitus.

Fig. 6. Retracting the medial vertex and remarking the symmetry of theellipse.

Fig. 7. Retracting the lateral vertex and remarking the symmetry of theellipse.

Mastectomy flap design 331


The lateral end of the ellipse is grasped with tissue forceps andretracted medially (Fig. 12). A rhomboid-shaped area of skin ismarked (Fig. 13) and de-epithelialized (Fig. 14). The grasped apexof this de-epithelialized skin is retracted medially and sutured intothe mastectomy wound. The de-epithelialized area and mastectomywound are closed transversely (Fig. 15).

Results/discussion

We have used the waisted teardrop design for 10 years andde-epithelialization of the lateral fold in 20 patients during thistime, with maintenance of the reduction at long-term follow-up.Transverse closure of the de-epithelialized skin produces apleated appearance that improves with time. Reduction of thelateral bulge is maintained. The technique can be combined with alipectomy.

The tension of the closure can be adjusted by the degree of manualtension applied during breast retraction; through experience, com-pensation can be made for tighter skin and firmer breast tissue. Thetechnique can also be used to plan excision of other masses such aslarge lipomata.

Our technique for designing the mastectomy flaps is simple,reproducible and requires no additional incisions or measurement

of skin flap lengths. It establishes the maximum amount of breastskin that can be safely removed and still enable adequate woundclosure. It produces a straight neat mastectomy scar, which is sur-gically aesthetic and provides an acceptable cosmetic result topatients.

Fig. 11. Post-mastectomy and axillary procedure in an overweight patient. Fig. 12. Retracting the lateral end of the ellipse.

Fig. 13. Marking redundant skin.

332 Thomas et al.


References1. Public Health Intelligence Group, Ministry of Health. Cancer in New

Zealand: Trends and Projections. [PDF on Internet]. Wellington:New Zealand, [published November 2002; Cited 26 March 2012.]Available from URL: http://www.moh.govt.nz/notebook/nbbooks.nsf/0/B005B6A9C2BB332DCC256C83006CF13D?opendocument

2. Farrar WB, Fanning WJ. Eliminating the dog-ear in modified radicalmastectomy. Am. J. Surg. 1988; 156: 401–2.

3. Nowacki MP, Towpik E, Tchorzewska H. Early experience with‘fish-shaped’ incision for mastectomy. Eur. J. Surg. Oncol. 1991; 17:615–7.

4. Gibbs ER, Kent RB 3rd. Modified V-Y advancement technique for mas-tectomy closure. J. Am. Coll. Surg. 1998; 187: 632–3.

5. Hussien M, Daltrey IR, Dutta S, Goodwin A, Prance SE, Watkins RM.Fish-tail plasty: a safe technique to improve cosmesis at the lateral end ofmastectomy scars. Breast 2004; 13: 206–9.

6. Devalia H, Chaudhry A, Rainsbury RM, Minakaran N, Banerjee D. Anoncoplastic technique to reduce the formation of lateral ‘dog-ears’ aftermastectomy. Int. Semin. Surg. Oncol. 2007; 4: 29.

7. Mirza M, Sinha KS, Fortes-Mayer K. Tear-drop incision for mastectomyto avoid dog-ear deformity. Ann. R. Coll. Surg. Engl. 2003; 85: 131.

8. Patkin M. Surgical heuristics. ANZ J. Surg. 2008; 78: 1065–9.

Fig. 14. De-epithelializing the lateral flap.

Fig. 15. The wound after closing.

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mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold

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