Surgical treatment for breast cancer has evolved over the years from the radical mastectomy (where the surgeon would have to remove all of the patient’s breast skin and tissue, pectoral muscle, and lymph) to less mutilating operations more customized to the patient’s needs, depending on their cancer and their body. More commonly performed breast cancer surgeries include the skin-sparing mastectomy and lumpectomy. Recently, nipple-sparing mastectomy has become an acceptable surgical option in some patients, allowing them to have nicer cosmetic results.

 

The breast surgeon or surgical oncologist performs the mastectomy, which involves removal of the breast tissue and possibly some of the lymph nodes, but leaves all of the overlying skin including the nipple and areola. Usually, they will send a biopsy of the tissue behind the nipple to pathology for immediate assessment to verify there is no evidence of a connection between the underlying cancer and the nipple-areola complex.

 

The plastic surgeon then begins the reconstruction. In order for a nipple-sparing mastectomy to have a reconstruction it is necessary that most (if not all) of the overlying skin have adequate blood supply. If the blood supply is compromised, the skin may die leading to exposure of the underlying reconstruction. If the blood supply is deemed adequate, the plastic surgeon will then move forward with the reconstruction that may involve placement of a temporary tissue expander or permanent implant, or possibly the patient’s own tissue.

 

There are some risks with this procedure and sometimes the tissue that was spared needs to be removed later because it isn’t healing properly.

 

The priorities and goals of the reconstruction after treatment of the cancer are in order: 1) symmetry, 2) a nice shape, and 3) desired size. The nipple is an integral component to both symmetry and shape. Ideally, the nipple is centered on the breast mound for both breasts.

 

Another goal in reconstruction is to minimize scarring, but in order to reach the goals of symmetry and shape, incisions that lead to more scars may be necessary.

 

At the time of the initial consultation, the patient’s condition, history, physical features and expectations will all be assessed by the surgeon. There are usually various reconstruction options. The reconstructive surgeon will make recommendations to help guide decision making based on information from the consultation.

 

It is important for patients to know that there are multiple options available in reconstruction. These include one or two stage implant reconstruction or using the patient’s own tissue (autologous reconstruction). Furthermore, there are various types of implant and autologous reconstruction; sometimes they are combined.

 

Nipple-sparing mastectomy with reconstruction can vary depending on the patient, whether one or both sides are treated and the type of reconstruction chosen. Average first-stage surgeries range from three to six hours operating time. Patients usually stay one night in the hospital for implant reconstruction and two to three nights for autologous reconstruction. Patients begin walking the night of surgery and slowly increase activity daily, but should refrain from heavy lifting (more than 10 lbs.) or strenuous activity for six weeks.