|Updated: May 2009
Types of Mastectomy
Along with the type of breast reconstruction, the design and quality of the mastectomy is a major factor determining the aesthetic result of the reconstructed breast. As multiple factors, such as breast size, skin quality, symmetry, desired breast size, location of the tumor, or preexisting scars determine the most suitable surgical approach, the design of the mastectomy needs to be carefully tailored to the individual patient and the type of reconstruction.
Mastectomy techniques have evolved considerably along with the development of breast reconstruction. A traditional mastectomy removes the central breast skin including the nipple and areola with the underlying gland, and leaves a scar across the central breast. The introduction of immediate breast reconstruction has changed the paradigm in favor of a skin-sparing approach. A skin-sparing mastectomy preserves most of the normal breast skin and allows for a reconstruction with more natural contour and less visible scars. The nipple and areola are removed for oncologic reasons as they are intimately associated with the underlying breast tissue. Large studies about the oncologic outcome of skin-sparing mastectomy suggest that it is equally effective as traditional mastectomy in clearing breast cancer. The reconstruction after skin-sparing mastectomy can be based on implants or autologous (the patient’s own) tissue and will include a nipple-areola reconstruction as a second stage.
More recently the concept of skin-sparing mastectomy was extended to preserve the nipple and areola (the pigmented skin around the nipple) in select patients. This technique is best suited for patients with favorable breast skin (no excessive ptosis or skin redundancy), and offers the most naturally appearing reconstructed breast. However, as the nipple is intimately associated with the underlying glandular breast tissue, nipple preservation is associated with potential oncologic concerns. Nipple-sparing procedures that were performed since the 1970s (subcutaneous mastectomy) showed an increased risk of cancer recurrence compared to traditional mastectomies. More recent studies, however, have defined criteria that allow the appropriate selection of patients, in whom occult cancer in the nipple is highly unlikely, and who may be candidates for a nipple-sparing mastectomy. Breast surgeons may consider a nipple sparing mastectomy in patients in whom the tumor is sufficiently small (typically less than 3-4 cm) and distant (at least 2-4 cm) from the nipple, or in patients undergoing prophylactic mastectomy. The reconstruction after nipple-sparing mastectomy can be based on implants or autologous (the patient’s own) tissue. Even though a nipple-areola reconstruction is not necessary, a second stage surgery to refine the reconstruction may be desirable to optimize the aesthetic outcome.
An areola-sparing mastectomy provides a naturally-appearing breast reconstruction that is almost comparable to a nipple-sparing mastectomy, while decreasing the oncologic concerns associated with a nipple-sparing mastectomy. With an areola-sparing mastectomy the pigmented skin around the nipple is preserved, while the underlying flap is used to reconstruct the nipple. Thus an areola-sparing mastectomy is best suited for patients with favorable breast skin (no excessive ptosis or skin redundancy), and who are candidates for autologous breast reconstruction (using a flap of the patient’s own tissue). If an implant reconstruction is utilized with a areola-sparing mastectomy, the nipple can later be reconstructed using the skin of the areola for the nipple mound.
In patients with significant breast ptosis and skin excess, the mastectomy can be designed utilizing a skin-reduction pattern as typically used in a breast reduction or breast lift procedure. This allows the removal of any excess skin in a manner that results in a more favorable shape of the reconstructed breast. Also, this approach may result in a less conspicuous scar as compared to a standard mastectomy approach.
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