Is it okay to dissect tissue at the sternum or violate the midline for flat closure in a bilateral mastectomy?

Dissection of Tissue at the Sternum for Flat Closure in Bilateral Mastectomy

Yes, it is acceptable to dissect tissue at the sternum and violate the midline for flat closure in bilateral mastectomy when necessary to achieve complete removal of breast tissue and optimal cosmetic results. 1

Surgical Principles for Bilateral Mastectomy

Tissue Removal Considerations

• Bilateral mastectomy performed for risk reduction should involve removal of all breast tissue (i.e., a total mastectomy) to maximize risk reduction benefits 1
• Complete removal of breast tissue is the primary goal, which may necessitate dissection across the midline when breast tissue extends to or crosses the sternum 1
• The procedure should prioritize both oncologic safety (complete tissue removal) and cosmetic outcome, particularly for flat closure 1

Surgical Technique for Flat Closure

• When performing bilateral mastectomy with flat closure, dissection at the sternum is often necessary to ensure:

  • Complete removal of all breast tissue 1
  • Smooth contour across the chest wall 1
  • Avoidance of residual tissue that could cause asymmetry or bulging 1

• Proper orientation of tissue specimens is critical during the procedure to ensure complete removal while maintaining good cosmesis 1

Midline Considerations

Crossing the Midline

• Breast tissue often extends across the midline, particularly in the upper chest region, making midline dissection necessary for complete removal 1
• There are no specific contraindications to dissecting across the midline in bilateral mastectomy when performed for appropriate tissue removal 1

Technical Approach to Midline Dissection

• When dissecting at the sternum:
  • Maintain meticulous hemostasis to prevent hematoma formation 1
  • Preserve adequate skin flap vascularity 1
  • Consider the final cosmetic appearance with the patient in upright position, not just supine 1

Cosmetic Outcomes

Optimizing Flat Closure Results

• A superior cosmetic effect for flat closure is usually achieved when:

  • All breast tissue is completely removed, including at the sternum 1
  • The chest wall contour is smooth and symmetric 1
  • Tissue reapproximation is minimized, as reapproximation that appears adequate with the patient supine often results in distortion when upright 1

• Proper skin incision placement and management are crucial for optimal cosmetic outcomes 1, 2

Potential Complications

Surgical Site Considerations

• Dissection across the midline carries similar risks to other aspects of mastectomy surgery 3
• Complications to be aware of include:
  • Pain (occurs in approximately 35% of bilateral mastectomy patients) 3
  • Infection (approximately 17% of cases) 3
  • Seroma formation (approximately 17% of cases) 3
  • Wound healing issues, particularly if skin flaps are compromised 3

Midline-Specific Considerations

• When dissecting across the midline, maintain adequate tissue thickness over the sternum to prevent adherence of skin to bone 1
• Avoid excessive tension on closure to prevent wound healing complications 1

Summary of Approach

• Dissection at the sternum and across the midline is acceptable and often necessary in bilateral mastectomy for flat closure 1
• The primary goals are complete breast tissue removal and optimal cosmetic outcome 1
• Proper surgical technique with attention to hemostasis and tissue handling will minimize complications 1
• The final cosmetic result should be evaluated with consideration of the patient in an upright position 1