Jennifer D. Son, MD, FACS, is a breast surgical oncologist and associate professor at MedStar in Washington, D.C., and Maryland. Dr. Son is a board-certified surgeon and a fellowship-trained breast surgeon who specializes in wireless lumpectomies, nipple-sparing mastectomies, and hidden scar technique for both benign disease and cancer. She has been published in over a dozen scientific papers. She is a member of the American Society of Breast Surgeons, the American College of Surgery, and the Society of Surgical Oncology. She is passionate about patient advocacy, research, and breast cancer disparities. She believes in empowering patients to help them make the best decision for them. You can follow Dr. Son on Twitter.
We have come a long way since the earliest surgeries for breast cancer in the late 1800s. Back then, the standard treatment was a radical mastectomy where the entirety of the breast, muscle, lymph nodes, and nerves were removed, which led to disfigurement. Since then, we have had many advances in chemotherapy, radiation therapy, hormonal therapy, and surgical techniques for treating breast cancer. We also know that doing more extensive surgery does not translate into better outcomes, a lowered risk of recurrence, or improved survival for patients.
Today, breast cancer is often treated with surgery and radiation therapy followed by systemic treatment, such as chemotherapy. For small tumors, a lumpectomy, also called breast-conserving surgery, can be performed. During a lumpectomy, only the tumor is removed, and the rest of the breast is left intact. Then, radiation therapy typically follows 4 to 8 weeks after surgery to decrease the risk of recurrence. Mastectomies are usually an option for this type of cancer, too, and may give patients the opportunity to avoid radiation therapy.
What are the different types of mastectomies?
The decision to choose one type of mastectomy over another will be made by the patient and their surgeon. When discussing mastectomy with the health care team, patients should first choose if they want breast reconstruction, which is surgery to recreate a breast using either tissue taken from another part of the body or synthetic implants. Reconstruction is covered by most health insurances as part of the Women’s Health and Cancer Rights Act.
There are 3 types of mastectomies that are performed for people with breast cancer and those at risk of developing breast cancer:
Simple mastectomy. A simple mastectomy is when there is no breast reconstruction. Instead, the surgeon performs a flat closure, which is also called “going flat.”
Skin-sparing mastectomy. During a skin-sparing mastectomy, the skin is saved, but the nipple is removed. With skin-sparing and nipple-sparing mastectomies (see below), reconstruction is performed with either implants or the use of one’s own tissue, known as autologous reconstruction.
Nipple-sparing mastectomy. A nipple-sparing mastectomy involves saving the skin and the nipple, essentially preserving the entire breast envelope. The option to save the nipple depends on the person’s anatomy and the size and location of the tumor. People whose nipple and areola sits below the breast fold, which is the area underneath the breast where the breast and chest meet, may not be candidates for nipple-sparing mastectomies. A person may also not be a candidate for nipple preservation if the tumor appears to involve the nipple or areola.
If preserving the nipple and areola is important to you but you are not a candidate for nipple-sparing mastectomy initially, talk with your doctor about whether a 2-stage operation may be an option for you. This would involve first having a lumpectomy with a breast lift to position the nipple at the appropriate anatomic location above the breast fold. Then, a nipple-sparing mastectomy would be performed 3 months afterward. This is usually performed when there is a low-grade, low-stage tumor.
When talking with your health care team about which type of mastectomy is recommended for you, some questions you may want to ask include:
Where is my tumor located?
Can my nipple(s) be preserved?
What will sensation feel like for me after a mastectomy?
What kind of breast reconstruction do you recommend for me?
If I cannot yet receive a nipple-sparing mastectomy, am I a candidate for a 2-stage surgery to eventually have a nipple-sparing mastectomy?
What can patients expect when having a mastectomy?
The time it takes for each type of mastectomy to be performed depends on whether 1 or 2 breasts are being operated on and whether reconstruction is being performed. Usually, the surgery will take between 2 and 6 hours.
Some hospitals discharge patients the same day of the surgery or the following day. If autologous reconstruction is performed, the hospital stay can be around 1 to 3 nights. Drains will be placed in the surgical wound at the time of surgery and will usually stay in place for 2 weeks.
Following discharge from the hospital, patients can expect to slowly recover at home. They can typically walk around, eat their normal foods, and shower. Exercise should resume 4 to 6 weeks after surgery, and there should be no heavy lifting for 4 weeks following surgery.
It is important to know that there are many options for surgical treatments for low-stage breast cancer. Remember that more extensive surgery does not translate to better outcomes. When considering mastectomy, be sure to speak with your provider about your treatment goals, appearance goals, and follow-up care and monitoring goals to choose the best option for you.
The author has no relevant relationships to disclose.