Who’s a Candidate for Skin-Sparing Mastectomy?

How to preserve breast for better post-op reconstruction.

By Kevin RR Williams

pink ribbon

HEALTH Esteemed beyond a source of infant nutrition, a woman's breasts are often viewed as symbols of femininity. Hence, a cancer diagnosis can strike an emotional blow. Firstly, it forces one to face their own mortality. Secondly, a woman can't help but wonder about post-operation disfigurement. So self-esteem is a valid concern to be addressed by oncologists and surgeons.

Viewer Discretion: During a radical mastectomy, the lymph nodes, breast tissue, the nipple and dark area around it called the areola may be removed along with part of the underlying muscle. This leaves a prominent scar such as the one depicted in the accompanying image. Surgeons prioritize curing the cancer over aesthetics. But radical mastectomy is not always required to halt the spread of disease. In fact, over the past decade, early detection and better techniques are diminishing frequency of radical mastectomies.

Is Breast Reconstruction Necessary?

Often dependent upon factors such as age, marital status, family support, and economics, women may decline breast reconstruction surgery. Insurance distinguishes between medical and cosmetic procedures, often requiring a significant financial expenditure for the latter. A cosmetic implant to restore volume and optional nipple reconstruction can be performed by plastic surgeons. Areola simulation can be achieved via skin grafting and/or tattooing.

Who's a Candidate for Skin-Sparing Mastectomy?

Some of the same women who choose garments to frame décolletage or highlight cleavage, view a nip-slip as crossing the line to pornography. Often such slips are pixelated or morticed on paparazzi photographs. This emphasizes society's association of nipples with sexuality. Hence some patients may consider an areola as essential to reconstruction, while others who prefer to have no protrusion through clothing may forego any nipple reconstruction.

A woman who has been unsatisfied with pre-surgical breast size or shape may have contemplated augmentation but decided against a solely cosmetic procedure. With a mastectomy under consideration, reconstruction surgery may provide an opportunity for a patient to achieve a more pleasing appearance than prior to the cancer surgery. If reconstruction is planned, skin-sparing (also called nipple-sparing or breast-sparing) mastectomy is something to be discussed with the oncologist and plastic surgeon.

Can the Breast Be Spared?

Nipple-sparing mastectomy is removal of affected breast tissue, without removal of any of the skin, nipple or the areola. Patients undergoing prophylactic mastectomies like Angelina Jolie with high risk but no detected cancer are ideal candidates for nipple-sparing or breast-conserving mastectomy.

Typically, one incision is made in the armpit and another below the breast, where it meets the chest to facilitate removal of breast tissue. This can maintain an ideal repository for implant or perhaps even eliminate the need for reconstruction. Two weeks prior to her nipple-sparing mastectomy, Jolie had an uncommon nipple-delay procedure performed. This severs blood vessels and other breast tissue beneath the nipple so it can become accustomed to getting blood supply from surrounding skin. This increases the chances of post-op nipple survival — particularly in patients who have had prior breast surgery.

Variations of breast-conserving surgery include lumpectomy (removal of the lump), quadrantectomy (removal of one quarter, or quadrant, of the breast), and segmental mastectomy (removal of the cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor).

Improvements in the total skin-sparing mastectomy technique have resulted in a successful intervention that is oncologically safe with high nipple viability and early low rates of recurrence. In multiple studies, skin-sparing mastectomy seems to be oncologically safe in patients undergoing mastectomy for invasive T1-T2 tumors, multicentric tumors, ductal carcinoma in situ or risk-reduction. But it is not a viable option for everyone. It should be avoided in patients with inflammatory breast cancer or in those with extensive tumor affecting the skin or nipple.

Psychological Impact of Mastectomy

Some feel a sense of empowerment and freedom following a mastectomy. Matuschka became a public model who proudly displayed her surgical scars in the August 1993 issue of The New York Times Magazine. Amidst criticism from members of The SCAR Project, she underwent reconstructive surgery 20 years later. One reader wrote The New York Times after seeing the cover: 'Now everyone has to know what I look like — I've hidden it from my husband all these years, and now you had to expose it.' This well illustrates how one's perception of this admirable aspect of female anatomy can be altered when facing surgery, immediately following mastectomy, and years later.

Tags: awareness, body image, controversy, NBCAM, need to know, womanhood

References
  1. Women Who Lose Breasts Define Their Own Femininity. nytimes.com
  2. Life After Mastectomy: Nipple Reconstruction. healthcentral.com
  3. Breast-Conserving Surgery. cancer.gov
  4. Angelina Jolie’s ‘Nipple Delay’ Procedure, Explained. nymag.com
  5. Skin-sparing mastectomy: an alternative to conventional mastectomy in breast cancer. Ramos Boyero M. nih.gov
  6. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Garwood ER, et al. nih.gov
  7. The model and the mastectomy: From Matuschka to Angelina. Garwood ER, et al. cbsnews.com
  8. Mastectomy image depicts pre-tattoo customer of Madame Lazonga.