Mastectomy is an operation in which the entire breast, usually including the nipple and the areola, is removed. Mastectomy is usually performed as a treatment of breast cancer.
In general, women with breast cancer can decide whether to be treated with a lumpectomy or a mastectomy.
A lumpectomy is the removal of the cancerous breast tissue as well as a surrounding rim of healthy breast tissue. A lumpectomy is a breast-conserving surgery that is usually followed by radiation therapy (high-dose
X-rays or other high-energy rays to kill cancer cells).
A woman may decide to have a mastectomy versus a lumpectomy based on the following:
- If the tumor is big and, after the lumpectomy, very little breast tissue would remain
- If she does not want to undergo radiation therapy after the surgery
- If she believes she will have less anxiety about a recurrence of breast cancer with a mastectomy
If the woman has tumors in more than one quadrant of the breast, most cancer doctors recommend a mastectomy.
Historically, a mastectomy for breast cancer included an axillary lymph node dissection (removal of many of the axillary lymph nodes). Over the last decade, the approach has changed slightly in that many women can undergo a sentinel lymph node biopsy (removal of the first few lymph nodes draining the tissue of the breast) rather than an axillary lymph node dissection. The nomenclature is such that a modified radical and a radical mastectomy include an axillary lymph node dissection as part of the overall procedure. With the adoption of sentinel lymph node biopsy in the treatment of early breast cancer, the nomenclature for mastectomy has also changed. Depending on the characteristics of the tumor, the breast, and the patient, the surgeon may choose one of the following types of mastectomies:
- Simple or total mastectomy: The surgeon removes the entire breast tissue but does not remove the muscle tissue under the breast. This mastectomy can be combined with a sentinel lymph node biopsy in any case of an early invasive cancer and in some cases of ductal carcinoma in-situ when a mastectomy is chosen as the treatment option. Any of these can also be combined with an axillary lymph node dissection (which by convention turns the total mastectomy into a "modified radical mastectomy"). There are several subtypes of simple or total mastectomy depending on how much skin is removed.
- Traditional: The surgeon removes an ellipse of skin that includes the skin of the nipple/areolar complex. This is the most commonly performed mastectomy. If the woman doesn't want immediate reconstruction or is not offered immediate reconstruction, the end result is a flat chest with a scar about 8 inches in length, usually oriented transversely.
- Skin-sparing: In addition to the breast tissue as noted, the only skin removed is that of the nipple and areola, usually through a circular incision around the areola. If the breast is large, the surgeon may have to make a "keyhole" incision (one that includes a straight incision in one direction, generally down) to allow removal of the breast tissue.
- Nipple-sparing: The surgeon makes an incision around the nipple but leaves the areola intact. Again, in order to remove all of the breast tissue, the incision will need to be bigger than what is achieved with removal of the nipple. This is often an
- Total skin-sparing: The surgeon removes the breast tissue but leaves all the skin (including the skin of the nipple and areola) behind. The incision can be place in the outer part of the breast, in the inframammary fold or around the areola.
In general, if leaving the skin of the areola and or nipple, some surgeons recommend that the woman have a tumor that is less than 2 centimeters in size and that is more than 2 centimeters away from the nipple. The skin-sparing mastectomies are ideal for patients undergoing prophylactic mastectomy. The skin-sparing, nipple-sparing, and total skin-sparing mastectomies are generally done in combination with immediate breast reconstruction. The benefit of these procedures is that more of the breast skin envelope is preserved to make it easier to recreate the breast. No randomized trial has been undertaken to evaluate if there is an increased risk of local (in the breast skin or on the muscle) recurrence with the skin-sparing techniques. Most surgeons estimate that preserving more skin increases the risk of local recurrence of the tumor by 1% or 2 % over 20 years (from 3%-5% for traditional to 5%-7% for skin-sparing).
- Modified radical mastectomy: This combines a simple or total mastectomy, including the skin of the nipple and the areola, and includes removal of most of the lymph nodes in the armpit (axillary nodes) using a 6- to 8-inch incision. A woman undergoing a modified radical mastectomy can have immediate or delayed breast reconstruction.
- Radical mastectomy: The surgeon removes the entire breast tissue, all the lymph nodes in the armpit, and the muscles of the chest wall (pectoral muscles) that lie under the affected breast. Radical mastectomy was common in the past; however, it is rarely performed now.
Leigh A Neumayer, MD, MS, FACS
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