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Black et al. Plast Aesthet Res 2023;10:31 https://dx.doi.org/10.20517/2347-9264.2023.04 Page 3 of 9

Figure 1. Breast size measurements that our institution takes preoperatively and uses to anticipate the risk of breast skin necrosis after
mastectomy. BC: breast circumference; NN: nipple-notch distance; NF: nipple-inframammary fold distance; BH: breast height; CW:
chest width.

These measurements not only provide valuable information during reconstruction, such as when selecting
tissue expander size or determining DIEP flap dimensions, but they also allow us to calculate breast skin
surface area through geometric approximations. In a prior study, we approximated surface area using a
cone without its base and a half ellipsoid, and showed that the risk of necrosis increases significantly with
2
surface area > 212 cm on conical estimation and > 308 cm on half ellipsoid estimation .
[21]
2
Mastectomy technique
Nipple-sparing mastectomy (NSM) has been shown to lead to psychosocial and sexual well-being compared
to skin-sparing mastectomy (SSM) . However, while NSM is oncologically safe, poor vascularity of the
[22]
[23]
nipple-areola complex (NAC) can negatively impact overall results . There is still inconclusive evidence
that NSM leads to higher rates of skin necrosis than SSM; Matsen et al. and Lee et al. demonstrated a
significant difference between the two, but Andersen et al. and Gould et al. found equal rates of skin
necrosis [7,17,18,20] . The decision to pursue NSM vs. SSM is thus one that must take into account the balance
between the risk of complications and quality of life, the comfort level of the breast surgeon performing the
procedure, and the risk of skin necrosis at each practitioner’s institution as surgical technique will vary.

One of the most significant contributors to breast skin necrosis, particularly in NSM, is the thickness of the
mastectomy skin flap. Prior studies have reported that mastectomy skin flaps less than 5-8 millimeters in
thickness place patients at increased risk of necrosis [13,15] . Frey et al. even introduced an incremental range of
[24]
ideal flap widths as a function of patient BMI . However, a predetermined thickness can be difficult to
implement practically due to benign variations in anatomy; the thickness of breast skin and subcutaneous
fat may not correlate with weight or age, and a distinct layer of superficial fascia may be present in only up
to 56% of patients [15,25] . As reconstructive surgeons, we rely on our breast surgery colleagues’ expertise in
determining the appropriate skin flap thickness, treading a fine line between adequate oncologic resection
and risking postoperative skin necrosis.

There are several surgical approaches for NSM, notably via inframammary fold (IMF), radial horizontal,
radial vertical, and periareolar incisions. Periareolar incisions encompassing more than 30% of the areolar
circumference are an independent risk factor for necrosis . In fact, periareolar incisions have been shown
[26]