I just read an article that said a lot of board-certified surgeons in CA reported they are still using traditional techniques for mastectomy, cutting across the whole breast and leaving unnecessary scars. Why would surgeons do that instead of using skin-sparing mastectomy technique? Is there any reason that would justify not performing a skin-sparing mastectomy in favor of a traditional (and disfiguring) mastectomy?
Doctor Answers 8
Nipple-sparing mastectomy provides the ultimate cosmetic result in breast reconstruction
The default technique of the breast surgeons I usually choose to work with is nipple-sparing mastectomy (NSM).
NSM is appropriate in the following situations:
- BRCA gene positive women seeking prophylactic mastectomy
- Women with a strong family history of breast cancer seeking prophylactic mastectomy
- Women with DCIS (non-invasive breast cancer)
- Women with small tumors at least 2 cm away from the nipple
My most recent blog post details the technique for NSM and reconstruction used in my practice.
NSM and immediate breast reconstruction using either implants in a single-stage or a tissue free flap has become the most popular procedure for reconstruction in my practice, as the cosmetic results are most similar to a cosmetic breast augmentation or lift!
I encourage you to do your homework, and to find a breast surgeon and reconstructive surgeon with a great deal of experience in NSM if this is the path you would like to take!
Karen M. Horton, MD, MSc, FRCSC
All breast cancers, like all breasts, are not the same
The choice of the type of incision for a mastectomy should first be aimed at treating the disease and second at getting the best cosmetic result. Cancers can be advanced, large, and found in larger breasted women, all of which do not lend themselves to a skin sparing approach. Remember, a longer incision does not necessarily equal a "disfiguring" operation when you take into account the whole purpose of the procedure: the cure of the cancer.
All breast cancers are not the same
Skin sparing mastectomies are a great advancement for breast cancer surgery. An extension of these is the nipple/areolar sparing mastectomy which give great results in the right patients. However, all breast cancers are not the same. Skin sparing mastectomy is best for small cancers that are not close to the skin. However, more severe cancers that are large or close to the skin, may require traditional modified mastectomy incisions. It is unclear from the report that you site whether the surgeons they surveyed perform traditional mastectomy some of the time or all of the time. I think that this clarification is important, since if you need a traditional mastectomy and the surgeon does not perform them, then you are not better off. It is important that you research all of your options before undergoing any surgery. Also, I would hope that most surgeons have your best interest at heart. It would be devastating if your cancer returned because an inadequate tissue (skin) resection was performed.
I hope this helps.
David Shafer, MD
Shafer Plastic Surgery - Manhattan
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Skin sparing isn't for everyone
The best candidates for a skin sparing mastectomy are those with early breast cancers and small to medium sized breasts. Those with larger breasts are often better served with a traditional mastectomy.
Large tumors is one
Skin sparing mastectomies can be performed in many situations. Some situtations where you would not use this technique would be in patients with larger tumors close to the skin, and also in patients that have very ptotic (sagging) breasts.
Demand better mastectomy scars!
As a surgeon who performs mastectomies, I have had many patients that I have successfully taken through nipple sparing mastectomy via an incision along the bra line that were told by other surgeons that this would not be possible. The number one reason surgeons make very large, very visible, and (in my opinion) unacceptable scars is because it is what is easiest for them to do in the OR. There are a few situations where the pattern of disease or the goals for reconstruction dictate that central tissue must be taken, and the scar must be placed there as a result. The excuse that it is "safer" or more curative to take more tissue (specifically the nipple and areola) is just not true and many studies and years of experience with hundreds of patients living long, healthy lives with beautiful results have proven this to be the case. If you have a surgeon that refuses to consider nipple sparing, ask why. There may be a valid reason, but even so, consider getting a second opinion as another surgeon may have more experience and be more comfortable with a smaller, more hidden approach. It is harder for us in the OR, but is always worth it for YOU!
Skin sparing mastectomy allows much better reconstruction
When a woman is diagnosed with breast cancer, the most important thing is to treat the cancer appropriately. It goes without saying that breast reconstruction, although important, is not as important as curing the cancer. However, if an equivalent cancer operation can be performed, and limit the amount of skin removed with possible preservation of the areola and/or nipple, the aesthetic outcome of the reconstruction will be MUCH better.
Skin sparing techniques can be controversial in certain scenarios, depending on multiple variables like the size, location, and type of cancer. A skin sparing technique may also not be appropriate for someone with very large or ptotic (sagging) breasts. The mastectomy will be performed by a general surgeon, and not all general surgeons are up on these techniques, or comfortable performing them. Make sure you get a couple opinions at least, regarding the type of mastectomy you will need. The general surgeon and plastic surgeon should both be comfortable with the plan for treating the cancer and reconstructing the breast.
Mastectomy depends upon training and the cancer
When I assist in breast reconstruction for a patient, I prefer to be present during the Mastectomy to help with the skin sparing part if it is feasible. It is not always due to the nature of the cancer (size and location.)
Not all general surgeons are comfortable performing skin sparing mastectomy or have the availability of plastic surgeons to help.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.