Who should get a mastectomy?

Mastectomy is the removal of the entire breast, including the nipple and areola. Women who are advised to have a mastectomy instead of lumpectomy are women who typically have had radiation to the breast, multiple tumors in the breast occupying several quadrants of the breast, extensive disease that occupies a large area of the breast tissue or a large tumor to breast volume ratio.

Some patients elect to have a preventive or prophylactic mastectomy if they have a strong family history of breast cancer or who test positive for certain genetic mutations like BRCA1 and BRCA2. Prophylactic mastectomy is a surgery designed to remove one or both breasts to dramatically reduce the risk of developing breast cancer. When a preventive type of mastectomy is performed, no lymph nodes need to be removed, since there is no evidence of cancer. Patients sometimes elect to have their ovaries removed at the same time.

At Midlands Clinic, your surgeon will explain your options to you in full, listening carefully to your questions and addressing each of your questions and concerns. While your surgeon will guide you in deciding which mastectomy to have, you will always have an active part of any decisions that directly affect your treatment.

Whether medically necessary or preventative, a mastectomy is a highly personal procedure, and there are several ways to approach the removal and optional reconstruction of breast tissue.

Total simple mastectomy

This is the complete removal of the breast, nipple, and areola. No lymph nodes from the axillae are taken. Recovery from this procedure, if no reconstruction is done at the same time, is usually one to two weeks. Hospitalization varies with each patient. For some, a simple mastectomy may be an outpatient procedure; others may require an overnight stay.

Skin-sparing mastectomy

This is the removal of the breast, nipple, and areola, keeping the outer skin of the breast intact. It is a special method of performing a mastectomy that allows for a good cosmetic outcome when combined with a reconstruction done at the same time.

Nipple-sparing mastectomy

A newer technique, this kind of mastectomy is reserved for a smaller number of women with tumors that are not near the nipple areola area. Your surgeon will make an incision on the outer side of the breast or around the edge of the areola and remove the breast tissue, removing the areola and keeping the nipple intact. This method typically involves simultaneous reconstruction.

Nipple and areola-sparing mastectomy

One of the latest specialty procedures, the nipple and areola-sparing mastectomy involves an incision on the side of your breast or in some cases, around the edge of the areola. The breast tissue will be removed and reconstruction is performed at the same time.

Scar-sparing mastectomy

In this form of surgery, great care is taken to minimize visible surgical incisions while removing affected breast tissue and preparing it for reconstruction. Often done as skin-sparing, nipple-sparing, areola-sparing, or a combination, it is not uncommon for an entire mastectomy procedure to be performed through an opening that is less than two inches in length.

No matter which type of mastectomy procedure chosen, women can undergo simultaneous breast reconstruction of any kind. While there is no medical need to delay reconstruction, the choice to do so is entirely up to the patient, her goals, and her life and lifestyle.

Breast Reconstruction

There are several methods of reconstructing the female breast mound. If the patient’s native nipple-areolar complex had to be removed at the time of mastectomy, all methods maintain the opportunity for a patient to undergo eventual nipple-areolar reconstruction or tattooing, should they wish to do so.

Timing of reconstruction:

Breast reconstruction can almost always be initiated at the time of mastectomy – called “immediate” breast reconstruction. However, for patients who have already undergone surgical treatment for their breast cancer or genetic predisposition, insurance companies typically cover “delayed” breast reconstruction years later. For patients who have undergone breast cancer treatment with a lumpectomy and are unhappy with any residual contour deformities, there are also reconstructive options that can be pursued.

Type of reconstruction:

Nationwide, reconstruction of the breast mound remains most commonly done with the use of implants. Typically, this is a process performed over two “staged” surgeries with use of tissue expanders and then a permanent implant containing either saline or silicone gel. However, there are new options that can allow some patients to pursue implant reconstruction in just one stage.

There are also options for breast reconstruction that involve only the patient’s own tissue, called autologous breast reconstruction. There are several areas of the body from which fat with and without skin can be borrowed to recreate a breast mound, but the most common include the abdomen and back.

Post-operative Recovery from breast reconstruction:

Recovery from breast reconstruction is more involved than recovery from mastectomy alone. Depending on the type of reconstruction, patients will often stay 1-4 nights in the hospital, longer for autologous reconstruction than implant reconstruction. Patients are often discharged home with drains that they must monitor. Activity restrictions are typical for a period of weeks. At times, patients undergoing a second stage of implant breast reconstruction, or reconstructive efforts following lumpectomy, may go home on the same day.

Ultimately breast reconstruction is best thought of as a process rather than a single procedure, but each additional step brings the patient closer to their desired aesthetic result. This process is very individualized in that there are several factors at play for each patient (desired size, need for or history of radiation or chemotherapy, smoking status, lifestyle, etc.) that contribute to making the decision as to how to proceed.