Two of the most important new developments in the surgical treatment of early-stage breast cancer include skin-sparing mastectomy and sentinel lymph node biopsy. Combining these surgical techniques may achieve an optimal aesthetic outcome while minimizing the potentially significant morbidity associated with axillary dissection. Therefore, we congratulate Stradling et al1 on their insightful article that carefully describes the surgical nuances of these combined operative techniques. However, one potentially critical aspect of the combined procedure was not addressed. This concerns the intraoperative identification of axillary lymph node metastases. The false-negative rate for the detection of axillary metastases using frozen section and touch preparation techniques has been reported to be as high as 89%; at our institution it is about 54%.2,3 Therefore, the true status of the sentinel lymph node may be available only after a permanent histologic examination several days following the procedure. Although the current standard of care is to perform a completion axillary lymph node dissection if a sentinel node is found to contain metastases, this can significantly affect immediate autologous breast reconstruction. At our institution and many others, the vessels of the thoracodorsal vascular system are the preferred recipient vessels for free transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction. In this situation, reoperative axillary surgery has the potential to compromise the vascular pedicle of the reconstructed breast. The presence of a plastic surgeon during reoperative axillary surgery may enhance the safety of this operation. Furthermore, the optimal time to remove additional axillary nodes may be after adjuvant therapy, allowing for the establishment of a local blood supply to the TRAM flap. Other options that would eliminate the risk of vascular injury during reoperation include the use of the internal mammary vessels as recipient vessels for a free TRAM flap or the use of a pedicled TRAM flap. New developments in breast cancer treatment necessitate a team approach with increased communication between the breast surgeon, pathologist, and plastic surgeon in planning surgery for these patients. It is also of utmost importance to inform patients of the potential implications of skin-sparing mastectomy with sentinel node biopsy and immediate free TRAM breast reconstruction.
Kuerer HM, Krishnamurthy S, Kronowitz SJ. Important Technical Considerations for Skin-Sparing Mastectomy With Sentinel Lymph Node Dissection. Arch Surg. 2002;137(6):746. doi: