Skin and Nipple Sparing Mastectomy
Reconstruction After Skin Sparing Mastectomy
With skin sparing mastectomy the general surgeon carries out the mastectomy through an incision that runs around the border of the areola with a short extension.
For some patients this allows for a single stage reconstruction. With a flap reconstruction, the breast is immediately filled with the transferred tissue. With implant reconstruction, the implant is placed so that the upper portion is covered by the pectoral muscle and the lower portion is covered by acellular dermal matrix. In this situation, it usually makes sense to utilize form stable implants, due to their more natural shape. For some patients the opposite breast can be modified at the time of the immediate reconstruction. For others it can be modified at the time of nipple reconstruction, which typically occurs several months later.
Single stage reconstruction, although appealing, may not obtain the ideal breast shape for all patients, so it is often necessary to do additional “touch up” operations as time progresses.
For this approach to be successful there must be very close coordination between the general surgeon and the plastic surgeon. The ideal patient is a woman with relatively small breasts who will not require radiation to the area of reconstruction. Often it makes the most sense to use a tissue expander at the time of skin sparing mastectomy and to proceed with expansion and a later outpatient surgery with conversion to a permanent implant and fat transfer.
Reconstruction After Nipple Sparing Mastectomy
The reconstruction of the nipple and areola, although a small step in terms of technical complexity, carries a very large degree of emotional and aesthetic power.
When the nipple is restored, the breast truly becomes a breast. With this in mind there is obvious appeal to the concept of preserving the natural nipple and areola. This is the basis of nipple sparing mastectomy.
The concern with nipple preservation is that it might increase the risk that a woman might experience a new breast cancer, since some breast tissue remains. Remember that all of the breast ducts lead to the nipple and areola.
There are some general surgeons and medical oncologists who categorically reject nipple sparing mastectomy and others who are advocates in very specific groups of patients. No one suggests that nipple sparing mastectomy is for every patient.
From the standpoint of the surgical oncologist, nipple-sparing mastectomy requires a change in surgical technique from that of the “standard” mastectomy.
The usual incision across the center of the breast is avoided. One common approach is for the surgeon to make an incision along the fold under the breast and another incision under the arm. There is a natural plane of separation between breast structure and the fat underneath the skin, and the surgeon must preserve this fat in order for the skin to heal properly. The ducts that lead into the nipple must be carefully cored out, and most surgeons send a biopsy from the base of the nipple to make certain that they have not missed an area of breast cancer.
The ideal patient for nipple sparing mastectomy is someone who has a relatively small breast, a small tumor that is not near the nipple, no family history of breast cancer, and who is not going to be treated with radiation.
Some surgeons feel that nipple-sparing mastectomy is a reasonable choice for women who are considering prophylactic mastectomy. Immediate reconstruction after nipple sparing mastectomy involves the placement of form stable implants that are covered by the pec muscle in their upper portions and by acellular dermal matrix in their lower portions. As with skin-sparing mastectomy, it is often desirable to carry out later fat transfer or other surgical adjustments in order to optimize the reconstructed breast.
Dr. John Q. Cook is experienced in a number of breast reconstruction techniques and works with patients to help them select the treatment option that is best for their individual goals. If you are interested in learning more about breast reconstruction surgery with Dr. Cook, contact his practice in Chicago at 312-751-2112 or in Winnetka at 847-446-7562.
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