Skin-Sparing and Nipple-Sparing Mastectomy
What are skin-sparing and nipple-sparing mastectomy procedures?
Traditionally, modified radical mastectomy has been the procedure for most women with invasive breast cancer. More recently, advances in surgical techniques have allowed doctors to preserve more of the breast without sacrificing treatment effectiveness. Skin-sparing and nipple-sparing mastectomies are two of these procedures gaining popularity.
In skin-sparing mastectomy, doctors remove all breast tissue under the skin plus the nipple and areola. They preserve as much of the breast skin as possible. This allows for mastectomy with immediate reconstruction using an implant. It can eliminate the need for a tissue expander to stretch the remaining skin over several months. It results in a more natural looking reconstruction and less scarring. If you do not want immediate reconstruction, your doctor may recommend a different mastectomy procedure. Other names for this procedure include skin-saving mastectomy and subcutaneous mastectomy.
Nipple-sparing mastectomy is a form of skin-sparing mastectomy. Doctors remove as much breast tissue as possible, but leave the nipple-areola complex intact. They check the tissue under the nipple for cancer cells. If cancer is present, doctors may convert the procedure to skin sparing and remove the nipple. Some doctors will treat the nipple with radiation therapy during or after surgery.
Nipple-sparing mastectomy often has the best cosmetic result after breast reconstruction. It looks the most like a natural breast. Retaining the nipple helps many women feel better about their bodies after losing a breast. Other names for this technique include total skin-sparing mastectomy and nipple-areola-sparing mastectomy. In an areola-sparing mastectomy, the doctor removes the nipple but leaves the dark areola skin in place.
Who performs skin- and nipple-sparing mastectomies?
General surgeons typically perform mastectomy procedures. Some general surgeons choose to specialize in treating breast disease and use the term breast surgeon. With skin-sparing and nipple-sparing mastectomies, surgical technique is very important. The surgeon must remove as much breast tissue as possible to reduce the risk of recurrence. This makes it essential to find a surgeon with plenty of experience with these procedures. You may want to look for a surgeon with a Mastery of Breast Surgery documentation from the American Society of Breast Surgeons.
Because breast reconstruction takes place at the same time as skin-sparing mastectomies, your breast surgeon will work with a plastic surgeon.
How are these mastectomies performed?
Doctors perform skin-sparing and nipple-sparing mastectomies in a hospital using a general anesthetic. You will sleep through the procedure without pain.
In a skin-sparing mastectomy procedure, the doctor makes an oblong incision around the nipple-areola complex. This removes the nipple, areola, and some skin around them. The doctor removes breast tissue through the incision. The doctor may also remove underarm lymph nodes to check for cancer spread.
For a nipple-sparing procedure, the incisions are different. Many doctors hide the incision under the breast in the breast fold. Another technique puts the incision in the underarm area. Less frequently, the incision starts at the areola and goes outward or downward. The doctor will remove as much breast tissue as possible. It is very important to be thorough. The doctor will test the tissue from under the nipple. If cancer is present, the doctor may need to remove the nipple with or without the areola. In experienced breast cancer centers, doctors can accomplish all of this through a two-inch or smaller incision.
For either procedure, a plastic surgeon will work with your doctor to reconstruct the breast. In most cases, it is an implant reconstruction. Once all procedures are complete, the doctor will close the incision with stitches and place a thin tube or tubes at the site. These tubes will drain fluid away from the surgical site. Your doctor will remove them at a follow-up appointment.
What to expect the day of your mastectomy
In general, this is what happens the day of your surgery:
- You will change into a hospital gown and consult with a preoperative nurse who may perform a brief exam.
- You will meet your anesthesiologist, talk about your procedure, review your medical history, and discuss the anesthesia you will have. Your anesthesiologist may also suggest you be given a sedative to help you relax before the team takes you to the operating room (OR).
- Once you are in the OR, your anesthesiologist will start general anesthesia. With general anesthesia, you won’t remember anything else until you wake up in the recovery room.
- In the recovery room, your team will monitor you as you wake, manage your pain, and when you are ready invite your friend or family member to be with you.
What are the risks and potential complications of skin- and nipple-sparing mastectomies?
Any time you have surgery, there will be risks and the possibility of developing complications. Although they are not common, complications can be serious and even life threatening. Complications can occur during the surgery itself or afterwards during recovery.
General risks of surgery
The general risks of surgery include:
- Reaction to anesthesia, such as an allergic reaction and problems with breathing
- Excessive bleeding
- Blood clot, particularly a deep vein thrombosis
Potential complications of skin- and nipple-sparing mastectomies
In most cases, skin-sparing and nipple-sparing mastectomy procedures are successful. When complications occur, they can include:
- Delayed tissue healing (rare)
- Fluid collection that your doctor may need to drain
- Lymphedema, or severe swelling after lymph node removal
- Nerve damage resulting in numbness, tenderness, or extra sensitivity at the site
- Scarring problems resulting in pain and an unacceptable appearance
There are some additional complications that can occur with nipple-sparing mastectomy including:
- Loss of nipple sensation
- Shrinkage or deformity of the nipple due to inadequate blood supply
- Tissue death resulting in the need for surgery to remove the nipple
Reducing your risk of complications
You can reduce your risk of certain complications by:
- Choosing a surgeon with documented expertise in nipple-sparing and skin-sparing mastectomy
- Following activity, dietary and lifestyle restrictions and recommendations before your surgery and during recovery
- Notifying your doctor immediately of any concerns, such as bleeding, fever, or increase in pain
- Taking your medications exactly as directed
- Telling all members of your care team if you have allergies
- Wearing a postsurgical support bra as directed after breast reconstruction
How do I prepare for these types of mastectomy?
There are steps you can take before surgery to help improve your comfort and outcome afterwards. You can prepare by:
- Answering all questions about your medical history, allergies, and medications you take. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.
- Getting preoperative testing as directed
- Losing excess weight before surgery through a healthy diet and exercise plan
- Not eating or drinking before surgery as directed. Your team may postpone your surgery if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.
- Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
- Taking or stopping medications exactly as directed. Your doctor will give you instructions for taking your specific medications and supplements.
Questions to ask your doctor
Making a list of questions can help you remember everything you want to ask during your appointments. Questions you may want to ask the doctor include:
- Why are you recommending this type of mastectomy for me? How do the outcomes compare with other types of mastectomy?
- Do you have before and after photos you can share with me?
- How many of these procedures have you performed? How often do you see complications?
- What is involved in the mastectomy surgery you are recommending? What other treatments will I need?
- What type of breast reconstruction is best for me and why?
- How long with the surgery take? When can I go home?
- What restrictions will I have after surgery? What kind of assistance will I need at home?
- When can I return to work and other activities?
- When will I start physical therapy? How many treatments are typically necessary for recovery?
- How will we manage my pain?
- What changes, if any, to my medication plan do I need to make?
- When should I follow up with you?
- How should I contact you after hours if I have a problem?
What can I expect after a skin- or nipple-sparing mastectomy?
Planning and preparing for a successful recovery starts with knowing what to expect.
How long will it take to recover?
It’s common to spend a 1 to 2 nights in the hospital after a mastectomy procedure. However, in some cases, you may go home the same day or after a 23-hour observation period. Since reconstruction takes place at the same time, recovery can be longer than just having a mastectomy. It can take 4 to 8 weeks or more to fully recover and return to the activity level you had before surgery. Your age and overall health can affect how quickly you heal.
Will I feel pain?
You will have pain and discomfort after both types of mastectomy. It’s important to properly manage your pain as part of your recovery. Staying comfortable lets you complete physical therapy and other rehabilitation activities necessary for smooth healing. Tell your doctor if your pain gets worse or changes in any way. It could be a sign of a complication.
When should I call my doctor?
If you have questions between appointments, call your doctor’s office. Your doctor will tell you how to get in touch after-hours with urgent concerns. Call doctor right away or seek immediate medical care if you have:
- Shortness of breath or other breathing problems
- Confusion or changes in level of alertness
- Chest pain, pressure or tightness
- Drainage of pus, redness or swelling around your incision
- It’s common to have a fever right after surgery. Your doctor will give you instructions about when to call for a fever.
- Trouble urinating or move your bowels
- Leg pain, redness or swelling, which could mean you have a blood clot
- Unexpected bleeding
How might skin- or nipple-sparing mastectomy affect my everyday life?
If you have nipple-sparing mastectomy, you still will need regular screening mammograms because some breast tissue can remain. You also will need to continue screening mammograms on the other breast. It’s also important to see your doctor regularly for follow-up exams. Mastectomy reduces the risk of local recurrence, but breast cancer can recur in other places in the body.
Women sometimes have difficult emotions after mastectomy. They often feel a sense of loss or a change in the way they view themselves and their bodies. This is one reason women pursue nipple-sparing mastectomy. Keeping the nipple and areola can be a boost psychologically because the breast retains much of its natural look. Even so, you still may have some emotions you need to process. Talking to a therapist or a trusted friend or family member can help you work through your emotions. Joining a support group is another option. Your doctor is good place to start if you’re looking for resources.
If your emotional problems persist for more than a couple of weeks, let your doctor know. It could be a sign of depression, which may need treatment. Symptoms of depression can include:
- Feeling fatigued or constantly tired
- Feeling sad, hopeless or worthless
- Having difficulty concentrating
- Having sleep problems
- Losing interest or pleasure in activities you used to enjoy
- Thinking about dying or wanting to die
There are solutions for your feelings and your doctor can help. Talk with your doctor and find out how to get started on the path of healing on the inside.