Perspectivising tumescent mastectomy: innovation in preserving mastectomy skin flap perfusion-a narrative review

Mastectomy is used in breast cancer treatment and as risk-reducing in women with genetic high risk of breast cancer. Immediate breast reconstruction including direct to implant but also autologous breast reconstruction is increasingly offered to women planned to have mastectomy. Either simple mastectomy or skin sparring mastectomy followed by immediate breast reconstruction, two specific issues are crucial. (I) Oncologic safety. That is, removal of any diagnosed pathologic finding, but also all breast tissue including the often breast tissue containing Coopers ligaments and thereby minimizing residual breast tissue. (II) Low complication rate. During mastectomy, the skin flaps are dissected from the breast gland. The interruption of blood supply to the skin flaps from below results in diminished perfusion of the skin flaps. This comprises a risk of necrosis and infection and ultimately prolonged time to adjuvant therapy, prolonged recovery, and possible loss of reconstruction. Tumescent technique with epinephrine solution meets both challenges, especially when used under visual guidance. It accentuates breast tissue and makes it easier to dissect the breast tissue and Coopers ligaments free from the subcutaneous fatty tissue. Furthermore, it is atraumatic and preserves the insulating fatty tissue and the blood supply running through this. Maintaining skin flap perfusion diminishes the risk of necrosis and infection. On top of that, tumescent mastectomy leaves more fatty tissue resulting in a more pleasant aesthetic result regardless of either simple or skin sparring mastectomy and regardless of either direct to implant or autologous reconstruction. The powerful ICGangiography, often used to assess areas with low perfusion and previously shown to be superior to clinical assessment, can, however, not be relied on when tumescent mastectomy technique has been used.