Cannula-Assisted Flap Elevation (CAFE): A Novel Technique for Developing Flaps During Skin-Sparing Mastectomies



One of the most challenging procedures in breast surgery is the skin-sparing mastectomy (SSM). Various techniques and incisions have evolved that characterize this procedure; however, what is common in all of them is the smaller the incision, the more difficult it is to develop the skin flaps.


A procedure was developed that incorporates the use of liposuction cannulas (without suction) to create the skin flaps. The technique and results are described in this manuscript.


From October of 2012 to April 2014, 289 mastectomies (171 patients) were performed using the CAFE procedure on women of all shapes and sizes. Postoperatively, no problems were experienced with flap viability using this technique. The main difference in side effects between the CAFE technique and other standard techniques for developing flaps in SSMs was more bruising than normal, but this resolved rapidly. The results for use of this technique were consistently impressive. The learning curve for this procedure is very short, especially for those who perform SSMs using sharp technique (scissors). Residents and fellows became proficient with the CAFE technique in a relatively short amount of time. Plastic surgeons were pleased with the cosmetic outcomes of their reconstructions that follow this type of mastectomy. Patients were extremely satisfied with their reconstructions as well.


Incorporating the use of liposuction cannulas (without suction) makes the creation of flaps for SSM a relatively simple and rapid method. It is especially useful to assist in developing skin flaps with even the smallest of skin incisions.

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  1. 1.

    American Cancer Society. Cancer facts and figures 2013. In: Society AC, ed. Atlanta: American Cancer Society; 2013.

  2. 2.

    Fisher B, Redmond C, Fisher ER, et al. Ten year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med. 1985;312(11):674–81.

  3. 3.

    Sarrazin D, Le MG, Arriagada R, et al. Ten year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol. 1989;14(3):177–84.

  4. 4.

    Fisher B, Anderson S, Bryant J, et al. Twenty year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41.

  5. 5.

    Veronesi U, Cascinelli N, Mariani L, et al. Twenty year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32.

  6. 6.

    Blichert-Toft M, Nielsen M, During M, et al. Long-term results of breast conserving surgery vs. mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized DBCG-82TM protocol. Acta Oncol. 2008;47(4):672–81.

  7. 7.

    Litiere S, Werutsky G, Fentiman IS, et al. Breast conserving therapy versus mastectomy for stage I–II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol. 2012;13(4):412–9.

  8. 8.

    Romics L Jr., Chew BK, Weiler-Mithoff E, et al. Ten year follow-up of skin-sparing mastectomy followed by immediate breast reconstruction. Br J Surg. 2012;99(6):799–806.

  9. 9.

    Cordeiro PG. Breast reconstruction after surgery for breast cancer. N Engl J Med. 2008;359(15):1590–601.

  10. 10.

    Zork NM, Komenaka IK, Pennington RE Jr., et al. The effect of dedicated breast surgeons on the short-term outcomes in breast cancer. Ann Surg. 2008;248(2):280–5.

  11. 11.

    Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048–53.

  12. 12.

    Carlson GW. Skin sparing mastectomy: anatomic and technical considerations. Am Surg. 1996;62(2):151–5.

  13. 13.

    Rand RP, Byrd DR, Anderson BO, Moe R. Skin-sparing mastectomy with immediate tissue reconstruction. West J Med. 1996;164(2):166.

  14. 14.

    Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg. 1998;102(1):49–62.

  15. 15.

    Shaikh-Naidu N, Preminger BA, Rogers K, Messina P, Gayle LB. Determinants of aesthetic satisfaction following TRAM and implant breast reconstruction. Ann Plast Surg. 2004;52(5):465–70; discussion 470.

  16. 16.

    Patani N, Devalia H, Anderson A, Mokbel K. Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction. Surg Oncol. 2008;17(2):97–105.

  17. 17.

    Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: a 6 year follow-up. Plast Reconstr Surg. 1999;104(2):421–5.

  18. 18.

    Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies. Ann Surg Oncol. 1999;6(7):676–81.

  19. 19.

    Rivadeneira DE, Simmons RM, Fish SK, et al. Skin-sparing mastectomy with immediate breast reconstruction: a critical analysis of local recurrence. Cancer J. 2000;6(5):331–5.

  20. 20.

    Spiegel AJ, Butler CE. Recurrence following treatment of ductal carcinoma in situ with skin-sparing mastectomy and immediate breast reconstruction. Plast Reconstr Surg. 2003;111(2):706–11.

  21. 21.

    Greenway RM, Schlossberg L, Dooley WC. Fifteen year series of skin-sparing mastectomy for stage 0 to 2 breast cancer. Am J Surg. 2005;190(6):918–22.

  22. 22.

    Carlson GW, Page A, Johnson E, Nicholson K, Styblo TM, Wood WC. Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy. J Am Coll Surg. 2007;204(5):1074–8; discussion 1078-80.

  23. 23.

    Lim W, Ko BS, Kim HJ, et al. Oncological safety of skin sparing mastectomy followed by immediate reconstruction for locally advanced breast cancer. J Surg Oncol. 2010;102(1):39–42.

  24. 24.

    Kinoshita S, Nojima K, Takeishi M, et al. Retrospective comparison of non-skin-sparing mastectomy and skin-sparing mastectomy with immediate breast reconstruction. Int J Surg Oncol. 2011;2011:876520.

  25. 25.

    Yi M, Kronowitz SJ, Meric-Bernstam F, et al. Local, regional, and systemic recurrence rates in patients undergoing skin-sparing mastectomy compared with conventional mastectomy. Cancer. 2011;117(5):916–24.

  26. 26.

    Tokin C, Weiss A, Wang-Rodriguez J, Blair SL. Oncologic safety of skin-sparing and nipple-sparing mastectomy: a discussion and review of the literature. Int J Surg Oncol. 2012;2012:921821.

  27. 27.

    Singletary SE. Skin-sparing mastectomy with immediate breast reconstruction: the M. D. Anderson Cancer Center experience. Ann Surg Oncol. 1996;3(4):411–6.

  28. 28.

    Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg Oncol. 1998;5(7):620–6.

  29. 29.

    Fersis N, Hoenig A, Relakis K, Pinis S, Wallwiener D. Skin-sparing mastectomy and immediate breast reconstruction: incidence of recurrence in patients with invasive breast cancer. Breast. 2004;13(6):488–93.

  30. 30.

    Woerdeman LA, Hage JJ, Smeulders MJ, Rutgers EJ, van der Horst CM. Skin-sparing mastectomy and immediate breast reconstruction by use of implants: an assessment of risk factors for complications and cancer control in 120 patients. Plast Reconstr Surg. 2006;118(2):321–30; discussion 331-2.

  31. 31.

    Meretoja TJ, von Smitten KA, Leidenius MH, Svarvar C, Heikkila PS, Jahkola TA. Local recurrence of stage 1 and 2 breast cancer after skin-sparing mastectomy and immediate breast reconstruction in a 15 year series. Eur J Surg Oncol. 2007;33(10):1142–5.

  32. 32.

    Vaughan A, Dietz JR, Aft R, et al. Scientific presentation award. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction. Am J Surg. 2007;194(4):438–43.

  33. 33.

    Omranipour R, Bobin JY, Esouyeh M. Skin-sparing mastectomy and immediate breast reconstruction (SSMIR) for early breast cancer: eight years single institution experience. World J Surg Oncol. 2008;6:43.

  34. 34.

    Stradling BL, Ahn M, Angelats J, Gabram SG. Skin-sparing mastectomy with sentinel lymph node dissection: less is more. Arch Surg. 2001;136(9):1069–75.

  35. 35.

    Simmons RM, Adamovich TL. Skin-sparing mastectomy. Surg Clin North Am. 2003;83(4):885–99.

  36. 36.

    Schrenk P, Woelfl S, Bogner S, Moser F, Wayand W. The use of sentinel node biopsy in breast cancer patients undergoing skin sparing mastectomy and immediate autologous reconstruction. Plast Reconstr Surg. 2005;116(5):1278–86.

  37. 37.

    Meretoja TJ, Jahkola TA, Toivonen TS, et al. Sentinel node biopsy with intraoperative diagnosis in patients undergoing skin-sparing mastectomy and immediate breast reconstruction. Eur J Surg Oncol. 2007;33(10):1146–9.

  38. 38.

    Ito K, Kanai T, Gomi K, et al. Endoscopic-assisted skin-sparing mastectomy combined with sentinel node biopsy. ANZ J Surg. 2008;78(10):894–8.

  39. 39.

    Rainsbury RM. Skin-sparing mastectomy. Br J Surg. 2006;93(3):276–81.

  40. 40.

    Baildam AD. Skin-sparing mastectomy. Eur J Cancer. 2011;47 Suppl 3:S342–3.

  41. 41.

    Carlson GW. Technical advances in skin sparing mastectomy. Int J Surg Oncol. 2011;2011:396901.

  42. 42.

    Burdge EC, Yuen J, Hardee M, et al. Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol. 2013;20(10):3294–302.

  43. 43.

    Petit JY, Veronesi U, Orecchia R, et al. The nipple-sparing mastectomy: early results of a feasibility study of a new application of perioperative radiotherapy (ELIOT) in the treatment of breast cancer when mastectomy is indicated. Tumori. 2003;89(3):288–91.

  44. 44.

    Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212(4):686–93; discussion 693-5.

  45. 45.

    Shoher A, Hekier R, Lucci A Jr. Mastectomy performed with scissors following tumescent solution injection. J Surg Oncol. 2003;83(3):191–3.

  46. 46.

    Chun YS, Verma K, Rosen H, et al. Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction. Am J Surg. 2011; 201(2):160–5.

  47. 47.

    Seth AK, Hirsch EM, Fine NA, et al. Additive risk of tumescent technique in patients undergoing mastectomy with immediate reconstruction. Ann Surg Oncol. 2011;18(11):3041–6.

  48. 48.

    Mlodinow AS, Fine NA, Khavanin N, Kim JYS. Risk factors for mastectomy flap necrosis following immediate tissue expander breast reconstruction. J Plast Surg Hand Surg. 2014;48(5): 322–6. doi:10.3109/2000656X.2014.884973.

  49. 49.

    Abbott AM, Miller BT, Tuttle TM. Outcomes after tumescence technique versus electrocautery mastectomy. Ann Surg Oncol. 2012;19(8):2607–11.

  50. 50.

    Khavanin N, Fine NA, Bethke KP, et al. Tumescent technique does not increase the risk of complication following mastectomy with immediate reconstruction. Ann Surg Oncol. 2014;21(2): 384–8.

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Correspondence to Michael D. Grant MD.

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Grant, M.D. Cannula-Assisted Flap Elevation (CAFE): A Novel Technique for Developing Flaps During Skin-Sparing Mastectomies. Ann Surg Oncol 22, 416–421 (2015).

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