INTRODUCTION
The skin-reducing mastectomy (SRM) is the best choice for patients with large and markedly ptotic breasts undergoing single-stage breast reconstruction with prosthesis. The Wise-pattern skin-reducing mastectomy is the most common technique, but it isn’t without complications. One of the hallmarks of the inverted-T resulting scar is the high incidence of dehiscence and wound healing problems. On the breast undergoing the Wise keyhole or inverted-T pattern skin-reducing mastectomy, the skin flaps are thin, and wound healing problems, particularly skin necrosis at the three-way junction are often described. This led various authors to seek alternatives 1–4.
In recent years, skin-reducing mastectomy has been performed with direct-to-implant (DTI) prepectoral breast reconstruction (PPBR) using prosthesis partially or completely covered by an acellular dermal matrix (ADM) 5-9. Indeed, different experiences point to the inverted-T closure as the main responsible for the onset of wound healing problems, considering that the very thin lower points of the vertical flaps carry a high risk of not being vascularly autonomous causing implant exposure. As a makeshift to this situation, placing a de-epithelised dermal flap underneath the three-way junction is a common expedient to avoid implant exposure in such risky cases. As well, some authors propose alternative types of skin closure, linear ones, that completely change the operatory planning and result in a biomechanically safer scar 10-12.
In the Nineteenth century, Langer explored the natural tension lines of the human skin drawing a map of how it stretches following puncture. Incisions performed following these directions proved to heal better due to the tension distribution on the cutaneous surface. Following Langer lines, incision on the breast should have medio-lateral directions following breast curvature, while rostrocaudal incision on the breast mound should be avoided13,14.
In 2022 Movassaghi and Stewart described their variation on the theme in prepectoral, two-stage prosthetic breast reconstruction named “smile mastopexy”. Their approach avoids the vertical scar and the T junction of the Wise-pattern reduction making the incisions according to Langer lines of the breast, improving scarring and reducing the risk of wound healing problems 2,14.
The physical and psychological burden of unexpected complications hits hard on patients and is a reason for frustration of the physician, so the objective of this work is to present a novel strategy for immediate breast reconstruction (IBR) in patients with large and ptotic breasts, which can reduce recovery time, complications, and improve the overall therapeutic experience for these breast cancer patients.
We present here the first report of an alternative DTI approach to smile mastopexy with symmetrical skin-reducing mastectomy and ADM-assisted prepectoral breast reconstruction.
MATERIALS AND METHODS
A prospective study of patients undergoing immediate, one-stage breast reconstruction with our technique of skin-reducing mastectomy and ADM-coated prepectoral implant from January 1st, 2019, through October 31st, 2022 was undertaken. We performed this technique in 17 patients. Inclusion criteria were patients who fulfilled the oncological criteria for skin-reducing mastectomy, with a grade of ptosis greater than 3 according to the Regnault classification, breast size greater than D or E cup (European standard), a pinch test at least 2 cm. All patients refused autologous breast reconstruction when indicated. Exclusion criteria included active smoking, poor patient performance status, and preoperative radiotherapy. A written informed consent document was signed by each patient. Operations were performed by the same team of a surgical oncologist and a plastic surgeon. All reconstructions were performed as a single-stage procedure. Clinical data included age, BMI, comorbidities, Jugular-nipple (J-N) distance, site and histology of the tumour, BRCA mutation, hospitalization days, drainages maintenance days, size of prosthesis used, radio and chemotherapy after the surgery, and complications. A Likert-scale questionnaire (Fig. 1) was administered to patients 3 months after the reconstruction. We considered a score ≥ 21/28 as a satisfactory result.
SURGICAL PROCEDURE
The preoperative project
Our procedure begins with a careful preoperative assessment. With the patient standing in front of the surgeon, first the position of the new nipple is marked along the midclavicular line at the level of the anterior projection of the IMF at a distance between 19 and 23 cm from the jugular point. The upper incision is marked in a curvilinear fashion with the middle point maximum 1cm above the edge of the nipple-areola complex (NAC). The middle point of the lower incision is marked maximum 1cm below the edge of the NAC. The lower incision marking is completed in a curvilinear fashion connecting with the medial and lateral extent of the upper line paralleling the Langer lines of the breast. The NAC is marked with a 4.2 cm diameter cookie cutter. At the same time the marking for the contralateral reduction mammoplasty or mastopexy are made (Fig. 2).
Surgery
First, the mark around the areola is incised and the NAC is removed as a graft. After that, the retroareolar tissue in all patients is biopsied and the NAC is preserved for the subsequent grafting if the fresh-frozen retroareolar biopsy results are negative. The breast surgeon performs the mastectomy and the lymph node surgery through the mastectomy incision if the sentinel lymph node biopsy is positive. The mastectomy incision is larger and allows for a faster and safer mastectomy. A sizer chosen based on the size of the breast is inserted. The patient is then placed in a semi upright position, the vascularity of the mastectomy flaps is verified with indocyanine green (ICG) fluorescent angiography, and the edges are trimmed off if hypoperfused. If the skin of the breast is too much compared to the dimensions of the prosthesis, the excess skin from the lower margin is de-epithelialized and a dermal flap which protects the prosthesis and ADM from a possible wound dehiscence is created (Fig. 3A-B). Starting from the lower margin, the breast can be lifted, reducing its ptosis. If there is still excess skin, the upper margin is also de-epithelialized (Fig. 4; Fig. 5). The aim is to recreate the best shape of the breast and, if it’s good, the relative anatomical silicone gel prosthesis (Mentor®, Mentor Medical Systems BV, Leiden, NL; part of Johnson & Johnson Inc., New Brunswick, New Jersey, US) covered with the ADM (Braxon®, Audio Technologies Srl, Piacenza, IT; licensed by DECO med Srl, Venezia, IT) is inserted in the prepectoral plane (Fig. 6). After implant positioning, fibrin sealant (Evicel®, Omrix Biopharmaceuticals Ltd, Aviv, IL; part of Johnson & Johnson Inc., New Brunswick, New Jersey, US) is sprayed to assure perfect adhesion with surrounding subcutis to avoid dead spaces, and one or two drains are placed in the mastectomy pocket. Two or three medial stitches are placed between ADM and pectoralis major to avoid lateral dislocation of the implant, this is made easier by the wide mastectomy incision. At that time, the defect is either closed primarily, the new NAC location is marked with a 4.2 cm cookie cutter on the point of maximum projection along the breast meridian previously drawn, the circle is de-epithelialized, and the cold-preserved native NAC is grafted as a full-thickness skin graft (Fig. 7A-B). A tie over dressing is placed to the graft to increase the chances of engraftment (Fig. 8). Symmetry with the other breast is checked and, if necessary, a contralateral reduction mammoplasty or mastopexy is performed.
RESULTS
A total of 20 procedures were performed in 17 patients (3 bilateral and 14 unilateral). The average age of the patients at the time of surgery was 56.1 years (range, 37 to 68 years) and the mean BMI was 23.36 kg/m2. There was a median follow-up of 30.5 months. The mean implant size used was 515 cc, the largest implant was 690 cc, and the smallest was 370 cc.
Three patients (17.6%) were at high risk because of BRCA genes mutations and, following diagnosis of breast cancer on one side, they decided to also undergo contralateral prophylactic mastectomy (Fig. 9A-F).
In two patients (11.8%) axillary dissection was performed through the mastectomy incision.
Thirteen (76.5%) contralateral symmetrisation procedures were performed in the same surgical setting: three breast reductions and ten mastopexies. The average of the jugular-nipple distance was 28,6 cm.
Six patients (35.3%) had one-stage nipple reconstruction in the operating room with nipple-areola skin grafts (one bilaterally).
The average hospital stay was 7,5 days (Tab. I).
Five patients developed minor complications successfully treated with wound care or a simple procedure in the office and did not result in reconstructive failure. Of these, seroma developed in 3 patients (the average drainage maintenance days were 21,4) (Fig. 10), red breast syndrome in 1 patient (Fig. 11), and a marginal necrosis of the superior mastectomy flap in 1 patient. Only 1 patient developed a major complication: an infection requiring implant replacement (Tab. II). During the follow up period we did not find any patients with capsular contracture or implant malposition.
We had a Likert-scale questionnaire response rate of 88.2%. A satisfactory result of breast reconstruction was reported by 86.7% of patients.
DISCUSSION
Breast cancer affects approximately 1 in 8 women in Western countries, profoundly impacting physical, social, and psychological wellbeing 16,17.
Surgical intervention is a critical therapeutic step, though recovery may be complicated by postoperative issues. These are commonly higher in cases of SRM followed by implant-based breast reconstruction in large and ptotic breasts, with vascular-related complications up to 27% 4,18,19.
Nava et alii first published the skin-reducing mastectomy technique using Wise’s incision pattern on large and ptotic breasts, allowing immediate direct-to-implant (DTI) breast reconstruction also for such patients. In Nava’s technique a de-epithelized dermal flap covers the inferolateral part of the subpectorally-placed implant, completing the subpectoral implant pocket, but its inverted-T closure is associated with wound healing problems at the caudal junction 21,22.
The combination of a skin-reducing mastectomy (SRM) through a Wise-pattern incision and ADM-implant reconstruction has been recently proposed by few authors to offer pre-pectoral breast reconstruction also to patients with large ptotic breasts. Various incision patterns have been proposed to balance oncological safety, flap perfusion, and aesthetic outcomes 3,10,20,21,23,24.
Alternative approaches include J-pattern incisions, which have been shown to reduce the risk of skin necrosis, simplify surgical design, and minimize scar impact by avoiding the medial quadrants of the breast 20.
Additionally, hybrid DTI techniques combining prepectoral implants with retropectoral fat grafting represent a promising option to reduce tension and optimize contour without adding complications 25.
In our cohort, we have identified the critical key points that lead to tissue loss. In particular:
- 1 The extent of the damage on the inferior pole vascular plexus following SRM with Wise pattern technique;
- 2 Implant weight on the on hypoperfused inferior pole;
- 3 All additional compression forces on skin flaps (containment bras, compression bandages, sutures that keep pillars together).
As we assumed that there are some risk factors that are intrinsic of the patients, the procedure, and the therapeutic course on which we have no control, we searched every single factor that could be modified, in particular:
- 4 Inferior pole scars: we designed an incision that creates a horizontal scar at breast midheight;
- 5 As long as many studies claim that pressure forces on sutures stimulate fibroblasts to produce a hypertrophic/keloid scar, moving scar to an area with less pressure allows fibroblast to perform a perfect scarring.
- 6 Hypoperfused tissues in lower pole: we consider a greater risk of tissue loss in this area, so double-layer closure with a de-epithelialized flap provide redundancy in case of marginal tissue loss.
Pillars stretched by anchoring sutures in Wise-pattern incision can cause not only a functional problem of tissue perfusion, but also an aesthetic problem: lower pole appears flattened and stretched. Avoiding Wise-pattern access also allows us to respect the natural aspect of a rounded lower pole.
This approach yielded low complication rates in a high-risk population: one implant infection requiring removal (5%) and one partial NAC necrosis (5%). Patient satisfaction was high (86.7%). The mean hospital stay was 7.5 days, which is slightly longer than typical DTI reconstructions but reflects that patients were admitted to the general surgery ward and received careful postoperative monitoring in this higher-risk cohort treated with a novel technique.
Average follow-up was 30.5 months, sufficient to capture early and mid-term complications, but not long-term risks such as BIA-ALCL or BIA-SCC 26,27.
Compared with conventional Wise-pattern SRM and alternative incisions, the smile mastectomy provides a biomechanically safer closure, lowers the risk of dehiscence, and preserves the natural breast contour, while maintaining oncological safety and enabling immediate DTI reconstruction. Incorporating hybrid techniques in selected cases may further optimize outcomes, particularly in patients with compromised tissue perfusion or high flap tension.
A major limitation of this study is the lack of a direct comparison with standard Wise-pattern SRM or other SRM techniques. Consequently, while the “smile mastectomy” appears to offer low complication rates and favorable aesthetic outcomes in our cohort, definitive conclusions regarding its superiority over alternative approaches cannot be drawn. Future prospective studies with comparative cohorts are warranted to validate these findings.
CONCLUSIONS
Therefore, even if the horizontal scar lays in a more visible place than the horizontal scar in wise-pattern procedures, this is our procedure of choice in patients with large/ptotic breasts that have to undergo SRM.
One of the main limitations of the study is the small number of cases and the lack of an internal control group, which may pave the way for further and more powerful analysis in the future.
We think this is a favourable compromise for a fast recovery, decreasing scars and the risk of complications that can keep patients far from their everyday life.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
RB, AF: A
DF: W, DT, S
GPA, XP: D
Abbreviations
A: conceived and designed the analysis
D: collected the data
DT: contributed data or analysis tool
S: performed the analysis
W: wrote the paper
Ethical consideration
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
History
Received: November 7, 2025
Accepted: February 9, 2026
Figures and tables
Figure 1. Patient satisfaction questionnaire.
Figure 2. Preoperative markings.
Figure 3. Marking for de-epithelization (A) and creation of the dermal flap (B).
Figure 4. De-epithelization and creation of a superior dermal flap.
Figure 5. De-epithelization and creation of the inferior dermal flap.
Figure 6. BRAXON®Fast ADM.
Figure 7. De-epithelialization (A) and full-thickness skin graft of the NAC (B).
Figure 8. Tie-over dressing for NAC skin autograft.
Figure 9. Preoperative (A-C) and postoperative pictures at 22 months (D-F) of one representative patients.
Figure 10. Seroma in a case of unilateral right-side reconstruction and contralateral Wise-pattern mastopexy.
Figure 11. Red breast syndrome in a unilateral case with contralateral Wise-pattern mastopexy.
| No. of patients | 17 |
| Unilateral breast reconstruction | 14 |
| Bilateral breast reconstruction | 3 |
| Average age, years | 56,1 |
| Average BMI (kg/m2) | 23,36 |
| Diabetes | |
| Yes | 1 |
| No | 16 |
| Indication for surgery | |
| DCIS | 3 |
| IDC | 11 |
| ILC | 3 |
| Prophylactic | 3 |
| Lymph node management | |
| SLNB | 15 |
| ALND | 2 |
| Radiation | |
| After reconstruction | 4 |
| None | 13 |
| Chemotherapy | 2 |
| NAC grafting | 7 |
| Contralateral symmetrisation | |
| Reduction mammoplasty | 3 |
| Mastopexy | 10 |
| No. of drains | |
| one | 7 |
| two | 13 |
| Average drainage maintenance days | 21,4 |
| Evicel | 18 |
| Medial stitches | 14 |
| Average jugular-nipple distance, cm | 28,6 |
| Mean hospitals stay, days | 7,5 |
| Average follow-up, months | 30,5 |
| Type of ADM | |
| Classic | 13 |
| Fast M size | 2 |
| Fast L size | 5 |
| Average permanent implant volume, cc (min-max) | 515 (370-690) |
| Complications | Rate (%) |
|---|---|
| Seroma | 3/20(15) |
| Hematoma | 0/20 |
| Rippling | 0/20 |
| Mastectomy skin flap necrosis | 1/20(5) |
| NAC necrosis | |
| Partial | 1/20(5) |
| Complete | 0/20 |
| Wound dehiscence | 0/20 |
| Surgical site infection | 0/20 |
| Red breast syndrome | 1/20(5) |
| Implant loss | 1/20(5) |
