731 Oncoplastic Technique for the elimination of the lateral “Dog Ear” During Mastectomy (Breast)
SHORT COMMUNICATION
Oncoplastic Technique for the Elimination
of the Lateral ‘‘Dog Ear’’ During Mastectomy
Krishna B. Clough, MD, Eleanore J. D. Massey, MRCS,
G. K. Mahadev, MD, MRCS, AFRCS, FRCS, Gabriel J. Kaufman, MD,
Claude Nos, MD, and Isabelle Sarfati, MD
The Paris Breast Centre- L’Institut du Sein
Abstract: Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral ‘‘dog ear.’’ This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast. The standard approaches to this operation of horizontal or oblique incisions often results in an
uncomfortable, unsightly lateral ‘‘dog ear’’. We describe a modification to the standard mastectomy incision that allows
extensive excision of the lateral adipose tissue, re-draping the skin over the chest wall, thus eliminating the ‘‘dog ear.’’ The
mastectomy is performed through two oblique incisions originating in the axillary skin crease encompassing the nipple areolar complex, followed by extensive lateral fat excision. A distance of 2–3 cm is kept between the superior limit of the two
incisions. At closure the lateral skin flap is advanced superiomedially on the chest wall without tension. This simple and
reproducible technique improves cosmesis and patient satisfaction following modified radical mastectomy by eliminating the
lateral ‘‘dog ear.’’ n
Key Words: advancement flap, dog ear, mastectomy, oncoplastic surgery
n
A
modified radical mastectomy can be performed by
a transverse incision or an oblique incision. In a
patient with large body habitus and an excess axillary
fat pad achieving a good functional and cosmetic
result can be challenging. Failing to address the axillary fat pad at the primary surgery may lead to lateral
skin folds, or ‘‘dog ears,’’ which are neither aesthetically pleasing nor comfortable (Fig. 1). Patients often
complain that this excessive fat pad overhangs the bra
causing discomfort. It is the breast surgeons’ responsibility to remove the excess fat pad during mastectomy,
thereby avoiding a lateral ‘‘dog ear’’ and the need for
further surgery, and ensuring optimal patient comfort.
Several techniques for addressing this problem have
been described and published (1–5). However, these
do not always satisfactorily address the issue and may
lead to further complications. The fish tail technique
(2,3) results in a T-junction which increases the risk of
wound tension, delayed wound healing, and necrosis.
Address correspondence and reprint requests to: Krishna B. Clough,
MD, Paris Breast Center-L’Institut du Sein, 7 Avenue Bugeaud, 75116 Paris,
France, or e-mail: [email protected].
DOI: 10.1111/tbj.12011
2012 Wiley Periodicals, Inc., 1075-122X/12
The Breast Journal, Volume 18 Number 6, 2012 588–590
We describe a new oncoplastic technique that
allows the elimination of the excess tissue with minimal skin loss. The two essential principles of this technique are the placing of an incision in the axillary
crease and the creation of a lateral skin flap for
re-draping the excess skin and fat medially. This medial
shift of excess skin eliminates the ‘‘dog ear,’’ enables
closure without tension, and leaves enough skin should
the patient choose to undergo reconstruction.
DESCRIPTION OF THE TECHNIQUE
Three mastectomy incisions are marked: two start
at the axillary fold. These two oblique lines are initially parallel then diverge as an ellipse to include the
breast (Fig. 2a,b). The medial incision initially runs
parallel to the lateral edge of pectoralis major then
curves over the breast superior to the nipple areolar
complex; the lateral incision starts 2–3 cm posteriorly
and angles toward the lower outer quadrant, then
curves back medially to join the first incision in the
lower inner quadrant (Fig. 3). The third incision is
placed in the axillary fold, extending from the medial
incision posteriorly for as much as is required to medialize the excess tissue. The mastectomy is completed
Oncoplastic Solution for a Mastectomy Dog Ear • 589
Figure 3. Detail of proximal incisions in relation to the muscles.
Figure 1. Post mastectomy ‘dog ear’ – the mastectomy was performed through a standard oblique incision.
(a)
(b)
Figure 2. Incisions. (a) Lateral View: The horizontal incision is in
the axillary fold. (b) Anterior View: The medial incision runs parallel
to the border of pectoralis major before curving medially.
Figure 4. Position of the final wound.
in a standard fashion. The tail of the breast is easily
visualized. The wide access allows extensive excision
of the excess axillary fat, including the fat lying
between the superficial fascia and the superficial, or
posterior, surface of the latissimus dorsi muscle. The
undermining should thus extend well below the anterior boarder of the latissimus. The lateral skin flap
should be thick enough to avoid any vascular risk
(1–3 cm). The lateral flap is then advanced superiormedially so as to re-drape the chest wall and close the
defect. Quilting of this flap to the anterior chest wall
will reduce the potential cavity and hence reduce the
post mastectomy seroma rate (6). The resulting wound
resembles an inverted ‘L’ (Fig. 4), with the axillary
incision completely hidden under the arm.
590 • clough et al.
excess volume and they can wear a bra with comfort.
The cosmetic outcome is considerably improved by
the absence of the ‘‘dog ear’’ and a streamlined silhouette. There is no functional disadvantage conferred by
these ‘L’ shaped incisions. There is no impingement of
the shoulder joint because they do not cross the axillary fold (7). They lie in an ideal location for future
reconstruction should the patient so wish. As long as
the skin flaps are not shaved too thinly, and the oblique scars are no more than 3 cm apart at their origin
allowing closure without tension, these scars heal well
giving a good aesthetic result (Fig. 5a,b). One should
not perform extensive resection of the axillary skin:
the dog ear is avoided by fat excision with medialization of the excess skin. Extensive skin resection in the
axillary fold leads to complications, such as delayed
wound healing and wound contracture.
(a)
(b)
CONCLUSION
Following mastectomy, patients with lateral ‘‘dog
ears’’ complain of long-term discomfort, unsightliness,
and difficulty wearing a bra. Although many different
techniques have been proposed, none of them have
emerged as standard, demonstrating the need for a
universal solution. This ‘L’ scar technique consistently
eliminates the excess lateral tissue. This surgical technique is simple, safe, and reproducible for obese
patients requiring mastectomy.
REFERENCES
Figure 5. Mastectomy through an ‘‘L’’ incision. (a) All the excess
lateral tissue has been excised. (b) The horizontal incision is in the
axillary crease and does not impair arm movement.
The skin is closed in two layers with 3 ⁄ 0 Monocryl,
with inverted dermal sutures and a subcuticular running suture. Two suction drains are usually placed:
one in the axilla and one in the mastectomy cavity.
DISCUSSION
There are two main benefits: functional and cosmetic. The patients no longer return postoperatively
complaining of having a ‘new breast’ beneath their
arm. Their arm movements are not impeded by the
1. Farrar WB, Fanning WJ. Eliminating the dog-ear in modified
radical mastectomy. Am J Surg 1988;156:401–402.
2. Nowachi MP, Towpik E, Tcho´rzewska H. Early experience
with ‘fish-shaped’ incision for mastectomy. Eur J Surg Oncol
1991;17:615–617.
3. Hussein M, Daltrey IR, Dutta S, et al. Fish-tail plasty: a safe
technique to avoid dog-ear deformity. Breast 2004;13:206–209.
4. Mirza M, Sinha KS, Forets-Mayer K. Tear-drop incision for
mastectomy to avoid dog ear deformity. Ann R Coll Surg Engl
2003;85:131.
5. Devalia H, Chaudhry A, Rainsbury RM, et al. An oncoplastic
technique to reduce the formation of lateral ‘dog-ears’ after mastectomy. Int Semin Surg Oncol 2007;4:29.
6. Kuroi K, Shimozuma K, Taguchi T, et al. Effect of mechanical closure of dead space on seroma formation after breast surgery.
Breast Cancer 2006;13:260–265.
7. Ed Edlich RF, Calr BA. Predicting scar formation: from ritual
practice (Langer’s lines) to scientific discipline (static and dynamic
skin tensions). J Emerg Med 1998;16:759–60.
Oncoplastic Technique for the Elimination
of the Lateral ‘‘Dog Ear’’ During Mastectomy
Krishna B. Clough, MD, Eleanore J. D. Massey, MRCS,
G. K. Mahadev, MD, MRCS, AFRCS, FRCS, Gabriel J. Kaufman, MD,
Claude Nos, MD, and Isabelle Sarfati, MD
The Paris Breast Centre- L’Institut du Sein
Abstract: Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral ‘‘dog ear.’’ This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast. The standard approaches to this operation of horizontal or oblique incisions often results in an
uncomfortable, unsightly lateral ‘‘dog ear’’. We describe a modification to the standard mastectomy incision that allows
extensive excision of the lateral adipose tissue, re-draping the skin over the chest wall, thus eliminating the ‘‘dog ear.’’ The
mastectomy is performed through two oblique incisions originating in the axillary skin crease encompassing the nipple areolar complex, followed by extensive lateral fat excision. A distance of 2–3 cm is kept between the superior limit of the two
incisions. At closure the lateral skin flap is advanced superiomedially on the chest wall without tension. This simple and
reproducible technique improves cosmesis and patient satisfaction following modified radical mastectomy by eliminating the
lateral ‘‘dog ear.’’ n
Key Words: advancement flap, dog ear, mastectomy, oncoplastic surgery
n
A
modified radical mastectomy can be performed by
a transverse incision or an oblique incision. In a
patient with large body habitus and an excess axillary
fat pad achieving a good functional and cosmetic
result can be challenging. Failing to address the axillary fat pad at the primary surgery may lead to lateral
skin folds, or ‘‘dog ears,’’ which are neither aesthetically pleasing nor comfortable (Fig. 1). Patients often
complain that this excessive fat pad overhangs the bra
causing discomfort. It is the breast surgeons’ responsibility to remove the excess fat pad during mastectomy,
thereby avoiding a lateral ‘‘dog ear’’ and the need for
further surgery, and ensuring optimal patient comfort.
Several techniques for addressing this problem have
been described and published (1–5). However, these
do not always satisfactorily address the issue and may
lead to further complications. The fish tail technique
(2,3) results in a T-junction which increases the risk of
wound tension, delayed wound healing, and necrosis.
Address correspondence and reprint requests to: Krishna B. Clough,
MD, Paris Breast Center-L’Institut du Sein, 7 Avenue Bugeaud, 75116 Paris,
France, or e-mail: [email protected].
DOI: 10.1111/tbj.12011
2012 Wiley Periodicals, Inc., 1075-122X/12
The Breast Journal, Volume 18 Number 6, 2012 588–590
We describe a new oncoplastic technique that
allows the elimination of the excess tissue with minimal skin loss. The two essential principles of this technique are the placing of an incision in the axillary
crease and the creation of a lateral skin flap for
re-draping the excess skin and fat medially. This medial
shift of excess skin eliminates the ‘‘dog ear,’’ enables
closure without tension, and leaves enough skin should
the patient choose to undergo reconstruction.
DESCRIPTION OF THE TECHNIQUE
Three mastectomy incisions are marked: two start
at the axillary fold. These two oblique lines are initially parallel then diverge as an ellipse to include the
breast (Fig. 2a,b). The medial incision initially runs
parallel to the lateral edge of pectoralis major then
curves over the breast superior to the nipple areolar
complex; the lateral incision starts 2–3 cm posteriorly
and angles toward the lower outer quadrant, then
curves back medially to join the first incision in the
lower inner quadrant (Fig. 3). The third incision is
placed in the axillary fold, extending from the medial
incision posteriorly for as much as is required to medialize the excess tissue. The mastectomy is completed
Oncoplastic Solution for a Mastectomy Dog Ear • 589
Figure 3. Detail of proximal incisions in relation to the muscles.
Figure 1. Post mastectomy ‘dog ear’ – the mastectomy was performed through a standard oblique incision.
(a)
(b)
Figure 2. Incisions. (a) Lateral View: The horizontal incision is in
the axillary fold. (b) Anterior View: The medial incision runs parallel
to the border of pectoralis major before curving medially.
Figure 4. Position of the final wound.
in a standard fashion. The tail of the breast is easily
visualized. The wide access allows extensive excision
of the excess axillary fat, including the fat lying
between the superficial fascia and the superficial, or
posterior, surface of the latissimus dorsi muscle. The
undermining should thus extend well below the anterior boarder of the latissimus. The lateral skin flap
should be thick enough to avoid any vascular risk
(1–3 cm). The lateral flap is then advanced superiormedially so as to re-drape the chest wall and close the
defect. Quilting of this flap to the anterior chest wall
will reduce the potential cavity and hence reduce the
post mastectomy seroma rate (6). The resulting wound
resembles an inverted ‘L’ (Fig. 4), with the axillary
incision completely hidden under the arm.
590 • clough et al.
excess volume and they can wear a bra with comfort.
The cosmetic outcome is considerably improved by
the absence of the ‘‘dog ear’’ and a streamlined silhouette. There is no functional disadvantage conferred by
these ‘L’ shaped incisions. There is no impingement of
the shoulder joint because they do not cross the axillary fold (7). They lie in an ideal location for future
reconstruction should the patient so wish. As long as
the skin flaps are not shaved too thinly, and the oblique scars are no more than 3 cm apart at their origin
allowing closure without tension, these scars heal well
giving a good aesthetic result (Fig. 5a,b). One should
not perform extensive resection of the axillary skin:
the dog ear is avoided by fat excision with medialization of the excess skin. Extensive skin resection in the
axillary fold leads to complications, such as delayed
wound healing and wound contracture.
(a)
(b)
CONCLUSION
Following mastectomy, patients with lateral ‘‘dog
ears’’ complain of long-term discomfort, unsightliness,
and difficulty wearing a bra. Although many different
techniques have been proposed, none of them have
emerged as standard, demonstrating the need for a
universal solution. This ‘L’ scar technique consistently
eliminates the excess lateral tissue. This surgical technique is simple, safe, and reproducible for obese
patients requiring mastectomy.
REFERENCES
Figure 5. Mastectomy through an ‘‘L’’ incision. (a) All the excess
lateral tissue has been excised. (b) The horizontal incision is in the
axillary crease and does not impair arm movement.
The skin is closed in two layers with 3 ⁄ 0 Monocryl,
with inverted dermal sutures and a subcuticular running suture. Two suction drains are usually placed:
one in the axilla and one in the mastectomy cavity.
DISCUSSION
There are two main benefits: functional and cosmetic. The patients no longer return postoperatively
complaining of having a ‘new breast’ beneath their
arm. Their arm movements are not impeded by the
1. Farrar WB, Fanning WJ. Eliminating the dog-ear in modified
radical mastectomy. Am J Surg 1988;156:401–402.
2. Nowachi MP, Towpik E, Tcho´rzewska H. Early experience
with ‘fish-shaped’ incision for mastectomy. Eur J Surg Oncol
1991;17:615–617.
3. Hussein M, Daltrey IR, Dutta S, et al. Fish-tail plasty: a safe
technique to avoid dog-ear deformity. Breast 2004;13:206–209.
4. Mirza M, Sinha KS, Forets-Mayer K. Tear-drop incision for
mastectomy to avoid dog ear deformity. Ann R Coll Surg Engl
2003;85:131.
5. Devalia H, Chaudhry A, Rainsbury RM, et al. An oncoplastic
technique to reduce the formation of lateral ‘dog-ears’ after mastectomy. Int Semin Surg Oncol 2007;4:29.
6. Kuroi K, Shimozuma K, Taguchi T, et al. Effect of mechanical closure of dead space on seroma formation after breast surgery.
Breast Cancer 2006;13:260–265.
7. Ed Edlich RF, Calr BA. Predicting scar formation: from ritual
practice (Langer’s lines) to scientific discipline (static and dynamic
skin tensions). J Emerg Med 1998;16:759–60.