The skin flaps for all mastectomies should be created between the breast capsule and the skin. A bloodless tissue plane is often identified with adequate retraction which can employ several skin hooks or facelift retractors. Thickness is dependent upon the patient and the amount of adipose overlying the breast tissue. No standard thickness exists, but the tissue remaining should, at a minimum, cover the dermal layer of the skin completely. If inadequate tissue remains, then there is a risk for skin necrosis. Dissection commonly employs cautery though more recently some surgeons are utilizing the lower energy devices such as ultrasonic or plasma blades. The borders of the dissection include the second rib superiorly, the upper border of the rectus sheath inferiorly, the lateral border of the sternum and the latissimus dorsi muscle laterally [3]. Another option to sharp mastectomy flap dissection is to use tumescent solution for mastectomy flap creation. The solution consists of normal saline, lidocaine and epinephrine. A 20 g spinal needle is used for infiltration in multiple locations once the skin edge is incised with a knife. The solution is injected into the breast/subcutaneous plane and then scissors are used to complete the flaps [4]. The surgeon performing the mastectomy needs to select the approach with which they achieve the lowest skin flap necrosis. Once the breast capsule has been dissected from the skin layer, the tissue should be removed from the pectoralis muscle. The overlying pectoralis fascia should but does not have to be included as well. This dissection is commonly performed in a superior to inferior fashion. The breast tissue should be retracted inferiorly for the duration of the dissection. Care should be taken to avoid entrance into the axilla laterally but should include the entire axillary tail breast contents. The fascia of the serratus anterior muscle should be left intact as well.

After removal of the specimen, the tissue should be oriented with sutures superiorly and laterally. The wound is copiously irrigated with water, and hemostasis is confirmed. The flaps should be examined in a systematic fashion, starting at the 12 o’clock position of the chest and working clockwise. Gently retract the skin and patiently observe for any bleeding. Cautery or a low energy device can be used, pending the thickness of the flaps. Re-examine the pectoralis muscle, along with any ligated vessel, to ensure adequate hemostasis.

A closed drain system should be used within the mastectomy bed. A 10 or 15 French drain is placed beneath the inferior flap with exit laterally. If a sizeable amount of tissue was removed with concern for a potentially large post-operative seroma, a second drain can be placed. The drains can then be sutured to the skin with either a nonabsorbable suture; usually a Nylon. Closure of the wound should then proceed with a 3-0 Vicryl suture, in an interrupted fashion, for the deep dermal layer and then an absorbable or non absorbable suture (removed post operatively) in the subcuticular space. Surgical glue can be used for incisional coverage vs steristrips. A fitted bra or breast binder can be placed with gauze for added support post operatively. There are several companies which have developed post mastectomy bras. The surgeon should select the one that works best for his/her patient population.