Although any surgical procedure requires a surgical incision, the visible scarring from an incision can be minimized. The Peg Procedure eliminates the typical mastectomy scar and replaces it with a circular scar that is hidden by the newly created nipple.

Table of Contents

Introduction   Lumpectomy   Conventional Radical Mastectomy
Skin-Sparing Mastectomy   Conventional Reconstruction
The Peg Procedure System   Breast Implants In Healed Mastectomies
Flaps vs. Implants   Bibliography

Introduction

According to the most recent statistics, one in eight U.S. women will develop breast cancer at some point in her lifetime. Breast cancer is a potentially fatal disease when diagnosis and treatment are delayed. This is especially true in younger, premenopausal women who typically have more aggressive tumors which are more likely to spread to other parts of the body by the metastasis of cancer cells. These women are especially at risk if definitive treatment is not initiated promptly. Inadequate initial treatment may be lethal to the majority of these younger patients, as a second chance to eradicate this disease is rarely granted.

There are currently two different ways to treat breast cancer: lumpectomy with radiation, and mastectomy. Each one leads to completely different patient outcomes. There are also two different types of mastectomy: conventional radical mastectomy (Figure 1) and a newer, skin-sparing mastectomy. (Figure 2)

In order to make the best decisions about her care, a patient must be fully informed about the benefits and potential side effects of all methods.

Lumpectomy

The first method of treatment, lumpectomy with radiation, is also called "breast conservation therapy." This method involves the removal of the breast cancer only, followed by radiation treatment of the remaining breast. This process may also involve the removal of lymph nodes in the underarm (or axillary) region to determine whether the cancer has spread to areas outside of the breast.

The main benefit of this approach is that the patient keeps her breast. The corresponding drawback is that the woman also keeps residual breast tissue. (Figure 3)

For older patients with a more limited life span, this approach has its greatest application because recurrent cancer in the treated breast tissue is less likely to occur than in the younger patient, who has a longer life expectancy.

There is also concern that the radiation treatment may itself prove to be carcinogenic after a five- to ten-year period. In addition, radiation scarring of the residual breast tissue may complicate follow-up surveillance by mammography. Many patients will require multiple breast biopsies to differentiate between scarring caused by radiation and actual recurring cancer in the residual breast tissue.

Of lesser oncologic importance are the more visible aesthetic side effects of radiation-induced scarring of the breast skin. The distortion and asymmetry of an irradiated breast can be severe if a large amount of breast tissue is removed during the lumpectomy. The breast skin, which is no longer supported by underlying breast tissue, may shrivel during radiation therapy. Typically, the treated breast will appear smaller and more contracted than the untreated, opposite breast. Furthermore, correction of these radiation induced deformities can be a challenging task for both the patient and the reconstructive surgeon.

Reconstruction can also be difficult for the unfortunate patient who was initially treated with radiation, but then required a subsequent mastectomy to treat a cancer recurrence in the residual breast tissue. In such a patient, the skin tightness that results from the mastectomy will aggravate the radiation scarring within the remaining skin. However, many of these serious complications can be avoided by restricting breast conservation treatment to older patients with small breast cancers.

Conventional Radical Mastectomy

The mastectomy has undergone little modification since the turn of the century and continues to be the preference of the general surgeon. This preference is based on established surgical convention which frequently ignores the possibility that a more conservative surgical approach may offer the same level of oncologic effectiveness. The modified radical mastectomy involves the complete removal of any remaining breast tissue through a large, elliptical section of breast skin, and includes removal of the areola and nipple.

The second typical way to treat breast cancer with mastectomy includes the additional removal of axillary lymph nodes to detect and halt the metastasis of cancer cells. With this "radical" approach, all of the remaining breast tissue is removed. In preventing recurrent cancer, this is a great benefit to patients because there is no residual breast tissue to act as a source of future tumors. Follow-up surveillance is simplified for this reason and subsequent breast biopsies are rarely required.

As expected, the recurrence rates for mastectomy are lower than for lumpectomy with radiation if patients are followed on a long-term basis. Early detection of a subsequent recurrence is easier because the residual breast tissue has been previously removed during the mastectomy. In contrast to lumpectomy with radiation,the thinner soft tissue layer (Figure 4) of a healed mastectomy will not disguise or delay the early diagnosis of a cancer recurrence.

Unfortunately, the oncologic effectiveness of mastectomy has always been accompanied by the unsightly breast deformity created by the procedure. For some women, the fear of mastectomy deformity has even led to the avoidance of early definitive treatment, which is so crucial for a long-term cure.

Nevertheless, mastectomy offers the greatest probability for good, long-term results, but it is not typically elected by younger patients as their first choice of treatment. For cosmetic reasons, many of these patients often choose radiation with lumpectomy -- which places them at a significantly greater risk of recurrence than a mastectomy. Until recently, none of the options presented to women with breast cancer provided a sense of complete and whole recovery. The trade-offs and compromises with each type of treatment were severe.

Skin-Sparing Mastectomy

Our goal has been to create a better surgical alternative that provides the full benefits of a mastectomy without the deformity. The following descriptions of the different types of skin-sparing mastectomy that we have developed will help patients understand the distinct advantages of these new surgical procedures.

Although the oncologic effectiveness of skin-sparing and radical mastectomies is identical, the skin-sparing techniques minimize trauma to the breast. Instead of making a large incision across the chest, the surgeon creates a smaller circular incision around the border of the areola (or colored circle around the nipple) to remove the remaining breast tissue and nipple. (Figure 5)

The breast skin is not routinely removed unless there is direct cancer involvement (a rare occurrence). This procedure requires a slightly more advanced approach by the general surgeon, however, the amount of additional training required is modest compared to other techniques.

Involvement of the skin from direct cancer invasion is rare and only occurs with more extensive breast cancers. For these few patients, a standard mastectomy with skin removal is required. However, the majority of patients do not require skin removal and can be provided with a skin-sparing mastectomy.

Skin-sparing mastectomy is only possible if all physicians involved in the care of the patient follow a specific treatment sequence, which we refer to as the Knowlton Breast Care Algorithm. Again, a periareolar biopsy (through the areola) is an important first step to start the cascade of events leading to a successful outcome. A periareolar incision allows the surgeon to make the initial diagnosis and also provides the means to perform a skin-sparing mastectomy. The skin around this initial biopsy incision should be subsequently removed during the mastectomy because the incision may be contaminated with cancer cells. All physicians must remember that any biopsy incisions outside the areola will require an unnecessary removal of breast skin which will lead to additional scarring and deformity.

Conventional Reconstruction

Another significant factor in the decision-making process that works against radical mastectomies is the failure of conventional reconstructive methods to create a natural-appearing breast. Many of these methods still leave significant scarring that serves as a constant reminder of the disease. With these older techniques, a single or double line of scarring extends across the reconstructed breast, which distorts contour and limits the creation of symmetry with the other breast.

Many of these techniques require large sections of skin and fatty tissue called flaps, which are moved into the mastectomy defect. These flaps of tissue are obtained from either the abdomen or the back and require large incisions in these flap donor sites. (Figure 6) Typically, the fatty soft tissue of the flap is used to replace the missing breast tissue. The skin of the flap is used to replace breast skin that was removed during the mastectomy. These procedures can also result in extensive scarring of the abdomen or back in addition to extensive scarring of the reconstructed breast. A skin pigment discrepancy (Figure 7) between the flap and the breast may also be evident to the patient.

The Peg Procedure System

In contrast to a conventional radical mastectomy (whether or not it includes reconstructive surgery), the Peg Procedure system of skin-sparing mastectomy is combined with a new method of breast reconstruction that reduces the long mastectomy scar across the chest to a smaller circular incision that is hidden within the reconstructed nipple. A round tissue "peg" is obtained from the back or abdomen and is then used to fill the round opening from the skin-sparing mastectomy.

After filling the round opening in the breast, the skin of the round tissue "Peg" is used to create the new nipple and areola. This new system of mastectomy and reconstruction consistently achieves symmetry with the opposite breast in addition to the recreation of the unique contours of the nipple and areola.

The recent development of Dr. Knowlton's ""Bowtie Method of nipple areolar reconstruction has provided the reconstructive surgeon with an essential tool to create these unique contours. Small modifications of bowtie-shaped incisions within the tissue Peg provide a means to selectively shape the new nipple so it is symmetrical with the other nipple. Additional incisions for skin grafts from the thigh are no longer required to complete this type of nipple-areolar reconstruction. (Figure 8)

The Peg Procedures are divided into two major classifications that use either tissue flaps or breast implants. The patient is provided with a choice between these two approaches that are based on the central theme of placing a "round peg into a round hole." In contrast to earlier flap methods that used large sections of skin and attached fatty tissue, a Peg Flap uses only a circular section of skin with attached fatty tissue.

Instead of a large elliptical section of skin that results in visible scarring across the reconstructed breast, the circular peg of skin is used only to recreate the nipple and areola. Any visible scarring is confined to the reconstructed nipple, which is further camouflaged with a dark pigment tattoo that corresponds to the color of the opposite nipple.

Since large flaps of skin are not required, a skin-sparing mastectomy and a Peg flap reconstruction can be typically completed in a single operation. In other words, it is finally possible for the patient to have her mastectomy and leave the operating room with her breast completely reconstructed in a single surgery. This single-stage approach takes place during a four- to five-hour operation and requires a three-day period of hospitalization.

Scarring is greatly diminished with the Peg Flap. However, an additional incision is required from the portion of the body from which the flap was taken. This portion of the body (either the abdomen or the back) is called the flap donor site. For the flap donor site on the abdomen, a horizontal ellipse of tissue is obtained that includes the rectus abdominus muscle. This muscle is included within the Peg Flap to provide needed circulation. Without circulation, the flap would not remain a living portion of the patient's body, a potential complication that must be kept in mind when choosing this approach.

In the past, the rectus abdominal operation was referred to as the "TRAM Flap" (Figure 9) and included a large ellipse of skin that did not fit into the reconstructed nipple area, but rather extended across the entire width of the reconstructed breast. For this reason, extensive scarring of the reconstructed breast could not be avoided. The Peg Flap uses this same abdominal tissue but limits the skin portion to a small circular section that is used entirely for the creation of the new nipple and areola. The underlying soft tissue of the flap is used as a "filler" of the reconstructed breast. Instead of the extensive double-tier scarring and pigmentary discrepancy of a TRAM flap, the scarring on the breast from a Rectus Peg Flap is confined to the newly created nipple and areola. (Figure 10)

A Peg Flap can also be made from back tissues that include the latissimus dorsi muscle. Similar to the rectus Peg Flap, a small circle of skin is included with the flap to create the nipple and areola.

Regardless of the flap donor site elected by the patient, the Peg Flap Procedure offers significant advantages over previous flap techniques that use large elliptical sections of skin.

Breast Implants In Healed Mastectomies

The other major classification of the Peg Procedure system involves the use of a breast implant for reconstruction. This recently developed technique is called the "Pectoralis Peg" and uses only the tissues from the healed breast. New growth of blood vessels into the skin of the mastectomy allows the creation of the circular peg of skin without a flap transfer from a different portion of the body, so additional incisions are not required. Although two separate surgeries are necessary, any visible scarring can be nearly eliminated. (Figure 11)

During the first stage of this technique, a skin-sparing mastectomy is performed with the insertion of a special saline implant that is designed for breast reconstruction. Referred to as a breast expander, this implant contains a valve that allows additional fluid to be injected into the implant after completion of the initial surgery. Breast expansion following mastectomy has been performed for several years to replenish the missing skin that was removed from a standard mastectomy. With the Pectoralis Peg Procedure, the expansion of the breast is not needed to replenish missing skin, but is used to create the nipple during the second surgery that is performed four months later. During this second-stage surgery, the smaller scar of a skin-sparing mastectomy is typically hidden within the boundary of the reconstructed nipple-areolar complex. Replacement of the breast expander with a permanent saline implant is commonly done at this stage. Both of these surgical stages are less extensive than the flap method, which requires a separate surgical incision on the abdomen or back.

Flaps vs. Implants

The use of breast implants significantly reduces the magnitude of any breast reconstruction procedure. Unfortunately, breast implants have been alleged as a contributory factor in patients who have arthritic-type diseases. However, recent studies have indicated that the risk of these arthritic diseases is extremely small. These studies have shown that the incidence of arthritic-type diseases is not any different than in women without breast implants. Nevertheless, any informed decision by the patient requires a thorough evaluation of all surgical risks including the more extensive flap procedures in which the patient herself is providing the "implant." These risks include abdominal wall weakness from a TRAM flap, which can be debilitating in rare circumstances. Infection, bleeding and anesthetic complications are unlikely, but occur more frequently in longer flap procedures.

In contrast to a flap method of reconstruction, a saline breast implant may require periodic replacement due to deflation. Scarring around the implant may also result in a condition called spherical contraction, in which the breast feels excessively firm. These implant complications are much less frequent, which makes breast reconstruction using implants an attractive alternative for the breast cancer patient.

A valid system of breast cancer care must take into account the unique differences of each patient. The Peg Procedures can be applied to women with various breast sizes and shapes including pre-existing mastectomy deformities. In addition, women with large breasts can electively choose a reduction in size during the same procedure. Pre-existing asymmetry of the breasts can also be corrected with this technique.

The Peg Procedure system of breast cancer care has great promise in providing the benefits of mastectomy without deformity. However, this system requires a coordinated effort of multiple specialists who are trained in its diagnostic and treatment components.

Bibliography

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