What are the recommended approaches for dermal enhancement in the breast?

Recommended Approaches for Dermal Enhancement in the Breast

The optimal approach for dermal enhancement in the breast involves oncoplastic volume displacement techniques that combine tissue removal with mastopexy techniques to maintain breast shape and volume while minimizing cosmetic deformity. 1

Surgical Approaches for Dermal Enhancement

Skin-Sparing Techniques

• Skin incision placement is critical for optimal cosmesis:

  • Curvilinear incisions following Langer's lines (natural skin tension lines) generally achieve the best cosmetic results 1
  • Radial incisions may provide better results at 3 and 9 o'clock positions and in the lower breast, particularly when skin removal is necessary 1
  • Avoid periareolar incisions for lesions in the periphery of the breast 1

• Skin management principles:

  • Preserve subcutaneous tissue with separate closure to improve cosmetic results 1
  • Use subcuticular technique for skin closure 1
  • Excision of skin segments should be minimized as it may alter nipple position or inframammary crease 1

Breast Tissue Management

• Tissue preservation techniques:
  • Excise primary lesion with rim of grossly normal tissue while avoiding excessive sacrifice of breast tissue 1
  • For lesions within breast substance, approach by incising overlying breast tissue 1
  • Superior cosmetic effect is usually achieved when breast tissue is not reapproximated 1
  • Meticulous hemostasis is critical to avoid hematoma formation 1

Advanced Dermal Enhancement Approaches

Oncoplastic Volume Displacement

• Oncoplastic techniques extend breast-conserving options when resection alone would yield unacceptable cosmetic outcomes 1
• These techniques combine:
  • Removal of breast tissue (designed to conform to segmentally distributed cancer)
  • Mastopexy techniques where remaining breast tissues are shifted within the breast envelope
  • Performed during the same operative setting as breast-conserving lumpectomy 1

Dermal Autoaugmentation Mastopexy

• Maintains maximal existing tissue volume with minimal tissue removal (average 11.3g per side) 2
• Uses flexible freehand shaping
• Ideal for cases where prosthetic implants are removed
• Requires minimal undermining and preserves blood flow to tissues
• Provides stable long-term results without revision, even in cases of dramatic laxity 2

Skin-Sparing Mastectomy with Reconstruction

• Appropriate for select patients - involves removal of breast parenchyma while preserving most of the original skin envelope 1
• Can be followed by immediate reconstruction with:
  • Autogenous tissue
  • Prosthetic implant
  • Composite of autogenous tissue and implant 1
• Nipple-areolar complex (NAC) sparing procedures may be considered in carefully selected patients 1

Non-Surgical Approaches

Vacuum-Based Tissue Expansion

• External soft-tissue expansion systems applying mild vacuum distraction force (approximately 20 mmHg) have shown effectiveness for non-surgical breast enlargement 3, 4
• One study showed average increase of 98% over starting size after 10 weeks of treatment, with stable long-term increase of 55% 4
• MRI confirmation shows proportionate enlargement of both adipose and fibroglandular tissue components 4
• Side effects may include brief occurrence of irritant contact dermatitis and folliculitis during therapy 3

Dermal Fillers

• Hyaluronic acid-based products can be used for superficial enhancement 5
• Often combined with other components like hydrolyzed collagen, ceramides, and peptides for comprehensive dermal support 5

Clinical Considerations and Contraindications

Radiation Therapy Considerations

• Radiation therapy significantly impacts breast reconstruction decisions:
  • Increased risk of implant capsular contracture after irradiation 1
  • May negatively impact breast cosmesis with autologous tissue reconstruction 1
  • Generally, radiation therapy should precede autologous reconstruction due to potential loss in reconstruction cosmesis 1
  • For patients requiring radiation therapy, staged approach with immediate tissue expander placement followed by implant placement is preferred 1

Patient Selection Factors

• Age and body mass index significantly impact outcomes of dermal enhancement procedures 6
• Axillary dissection is an independent risk factor for developing complications 6
• Previously radiated patients should avoid tissue expanders/implants due to increased risk of complications 1

Common Pitfalls and Complications

• Hematoma formation: Produces changes difficult to interpret by physical examination and mammography; meticulous hemostasis is critical 1
• Seroma formation: Reported in 7.2% of acellular dermal matrix cases 6
• Infection: Can lead to reconstructive failure (3.3% in acellular dermal matrix cases) 6
• Poor cosmesis: Can result from inappropriate incision placement, excessive tissue removal, or improper reapproximation 1
• Capsular contracture: Significantly increased risk after irradiation of an implant 1

By following these guidelines for dermal enhancement in the breast, surgeons can achieve optimal cosmetic outcomes while maintaining oncologic safety when applicable.