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Breast Reconstruction Outcome Also Depends on Mastectomy Technique

Last night I was talking to Dr. Kim Grafton, one of the general surgeons that I sometimes work with in Santa Barbara on breast reconstruction cases, and we were discussing nipple-sparing mastectomy. This has been a somewhat controversial procedure, as many surgeons and oncologists have been hesitant to leave behind the nipple, for fear that the ducts that travel through it may harbor residual cancer. As in many aspects of surgery, new trends take a while to take hold and are often met with resistance by more traditional surgeons. Mastectomy has evolved from the old radical mastectomy performed by Halsted over a hundred years ago, to more limited mastectomies, then to skin sparing mastectomy (limiting the amount of skin removed), then skin and areola sparing mastectomy, and more recently to skin, areola, and nipple sparing mastectomy. Lumpectomies (taking only the tumor and leaving most of the breast tissue) are common, and generally don’t require reconstructive procedures. With the development of other adjunctive diagnostic procedures and therapies, a more limited procedure that once may have seemed too risky from a cancer-recurrence standpoint has become safer, and more accepted.
This is all good news from a breast reconstruction standpoint. The more breast skin (and nipple and areola) the plastic surgeon has to work with, the better result he or she can obtain. Whether implant breast reconstruction, or autologous breast reconstruction is chosen, the ultimate appearance will be better the more actual breast skin, nipple, and areola remain. It may also allow a breast reconstruction endeavor that would normally take three surgical stages over many months to be consolidated into one or two surgical procedures. A nipple and areola that needs to be completely reconstructed ‘de novo’ using skin flaps, skin graft, and maybe even tattooing, can look pretty good, but never as good as the real thing. When reconstructing only one nipple/areola, it will never perfectly match the opposite, normal side. So if the nipple, or even just the areola, remains, we have a better shot at making a better looking reconstruction.
Now, the bad news is that even if someone would be eligible from a cancer standpoint to have an areola or nipple sparing mastectomy, she may still not be a candidate for it. Why? Leaving more ‘native’ skin and nipple/areola behind at the time of the mastectomy leaves more tissue that still needs a robust blood supply, now coming from the peripheral skin and no longer from the breast underneath, which has been removed. If someone is obese or has large breasts, or smokes, they may not have enough blood flow to preserve the nipple and areola and surrounding skin. Placing implants underneath tissue that is destined to necrose (die) because of poor blood supply is a recipe for disaster.
Nipple or areola sparing mastectomy is certainly not for everyone needing a mastectomy for breast cancer, but when it can be safely done, the possibility of a very aesthetic breast reconstruction is much greater. Women diagnosed with breast cancer should consult with a general surgeon who is versed in these techniques, as well as a plastic surgeon that has experience with breast reconstruction after skin sparing, and nipple-areola sparing mastectomies.

Douglas J. Mackenzie, M.D., F.A.C.S.
Santa Barbara, CA

Douglas J. Mackenzie, MD

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