Mastectomy

A mastectomy should be performed if:

 

  • The tumor is large compared to the overall size of the breast. When the tumor is very large, chemotherapy can be administered pre-operatively to reduce its size. When the tumor responds to the chemotherapy, breast-conserving surgery may be possible. As a general rule, if more than 1/8 of the breast volume needs to be excised, the aesthetic result after treatment (breast conserving surgery and radiotherapy) will be quite poor, mainly due to the effects of the radiotherapy.
  • Prophylactic mastectomy (see below): The breast is removed before a cancer occurs. This is recommended for women with a strong genetic predisposition to breast cancer.
  • Multifocal tumors: when two or more malignant tumors are present in different quadrants of the same breast; or if a malignant tumor is surrounded by satellite lesions; or there is a large area of dysplastic tissue; or there are multiple areas of carcinoma in situ.
  • Women who have previously been irradiated. This may be the case in patients who have certain forms of leukemia or who have previously undergone breast-conserving surgery combined with radiotherapy and now are confronted with a recurrence.
  • Severe comorbidities: in elderly women or women who have severe heart or blood vessel disease, severe lung disease or a combination of the above, it is prudent to perform a short procedure. Particularly if the entire breast is removed, one can be sure that no additional surgery will be necessary.
  • Tumors that have eroded through the skin.
  • A woman who choses to have her breast completely removed.


In many breast cancer patients, unfortunately, a mastectomy is still required. Fortunately we have moved away from the conventional radical mastectomy and in the majority of cases a modified radical mastectomy is performed.


Even less radical surgery can be offered to patients, depending on their tumor:

 

  • Skin sparing mastectomy involves resection of the nipple-areola complex together with the underlying mammary gland but preservation of the skin envelope. Often, the entire gland can be removed through a periareolar incision but if necessary, a short vertical incision can be added in the mid-areolar line.
  • Areola sparing mastectomy preserves the entire skin envelope and areola but sacrifices the nipple. A vertical incision is made at the mid-areolar line and continued to approximately 1 cm above the infra-mammary fold, to protect this anatomically important structure. The nipple is then removed together with the underlying mammary gland (fig 1.).
  • In many prophylactic mastectomy cases, a subcutaneous mastectomy is performed, retaining the entire nipple-areola complex. Incisions can be made in the mid-areolar line, in the inframammary fold or through any type of breast reduction/mastopexy pattern incision.
Type of mastectomy or partial gland removal Anatomical structure that is removed
  Breast gland Nipple Areola Breast skin axillary lymph nodes pectoralis muscle internal mammary lymph nodes
Extended Radical Mastectomy X X X X X X X
Radical Mastectomy (Halsted) X X X X X X  
Modified Radical Mastectomy (Madden & Patey) X X X X X    
Simple Mastectomy X X X X      
Skin Sparing Mastectomy X X X        
Areola Sparing Mastectomy X X          
Subcutaneous Mastectomy X            
Segmentectomy, Quadrantectomy Partial     +-      
Tumorectomy Small part            

 

 

fig.1: Steps in an areola-sparing mastectomy. (a) skin incision for an areola-sparing mastectomy, splitting the areola into two halves and extending to about 1 cm above the inframammary fold; the nipple will be removed. (b) an elliptical skin island of the free flap is fit within the mastectomy skin edges. (c) this skin is used in the second procedure to reconstruct the nipple by means of a modified C-V flap technique. (d) after removal of redundant free flap skin, the wound edges are closed to restore the round shape of the areola and finish with a vertical infra-areolar scar. The new nipple still needs to be pigmented by tattooing during a short third session.

Depending on the patients’ wishes and the breast size and shape, a skin-sparing mastectomy can be combined with either reduction of the skin envelope or a breast lift procedure.


To achieve the best aesthetic result in an immediate reconstruction, it is important to preserve the inframammary fold, the pectoral muscles and the skin envelope during the mastectomy. If any of these anatomical structures are disrupted, they should be repaired before introducing an implant or autologous tissue.


In particular, if there is a deficiency in the skin envelope, then this needs to be addressed. In an immediate autologous reconstruction, the skin can be replaced with skin from the flap. In the case of implant based reconstruction, the extra skin has to be recruited by gradual tissue expansion.


When a patient presents requesting a delayed breast reconstruction, the surgeon has to assess the level of post-ablative damage and the effect of any previous radiotherapy on the chest wall. The more aggressive the initial ablative surgery, the higher the dose of radiotherapy administered (or sensitivity to the radiotherapy), the higher number and type of previous reconstructive attempts and the absence of the nipple-areolar complex, all make the reconstructive procedure more complex and adversely influence the final result.

Examples of different types of mastectomies:

 

Figure above: schematic drawing and clinical example of a patient who has undergone a modified radical mastectomy without reconstruction.

Figure above: schematic drawing and clinical example of a patient after a skin sparing mastectomy and an immediate autologous breast reconstruction. A nipple reconstruction still needs to be performed.

Figure above: schematic drawing and clinical example of a patient who underwent an areola-sparing mastectomy and an immediate autologous breast reconstruction.

Figure above: schematic drawing and photograph of the same patient as figure 3 after nipple reconstruction and tattoo of the nipple-areolar complex.

Figure above: schematic drawing and clinical example of a patient who underwent a subcutaneous mastectomy through an infra-mammary incision. She underwent a delayed autologous breast reconstruction through the same incision in a 2nd operative procedure.


References

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Chen CM, Cano SJ, Klassen AF, King T, McCarthy C, Cordeiro PG, Morrow M, Pusic AL. Breast J. 2010 Nov-Dec;16(6):587-97.

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Munhoz AM, Montag E, Arruda E, Brasil JA, Aldrighi JM, Gemperli R, Filassi JR, Ferreira MC. Breast. 2011 Jun;20(3):233-40.

  • What options for treatment of hereditary breast cancer?

Narod S. Lancet. 2002 Apr 27;359(9316):1451-2.

  • Conservative mastectomies.

Nava MB, Catanuto G, Pennati A, Garganese G, Spano A. Aesthetic Plast Surg. 2009 Sep;33(5):681-6.

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