Most women with a new breast cancer diagnosis are candidates for breast conservation surgery. However, for some, mastectomy is still the best choice.

Woman more likely to be offered mastectomy are those whose tumors are large compared to the size of their native breast. However, pre-operative drug therapy can often reduce the size of these tumors enough to allow lumpectomy, AND a good cosmetic result.

Multiple cancers in the same breast lead many surgeons to automatically recommend mastectomy. However, with aggressive oncoplastic approaches these women may have excellent cancer AND cosmetic results.

For other women, prior lumpectomy and radiation therapy is an automatic indicator for mastectomy. But, for mature women with a low-risk, same-side, breast cancer, conservation without radiation remains a reasonable option.

Women with a new breast cancer diagnosis and a high-risk germline mutation, like BRCA1 and BRCA2, frequently feel obliged to proceed to mastectomy. Mastectomy may be a reasonable choice. But, it is not the only choice. A careful risk assessment and an understanding of available screening and prevention options, may play a role. For some patients, mastectomy may be avoided, while for others it is the best choice.

Many women still believe that mastectomy is the more “potent” treatment, offering a better chance for cure. But for patients who are good candidates for breast conserving surgery, well-controlled studies have shown no better outcome for women undergoing mastectomy versus “lumpectomy”.

For those women in whom mastectomy IS the right choice, a simultaneous plan for reconstruction works to keep a sense of wholeness and self. Saving the nipple and skin is often possible. For those with very large breasts, nipples may be saved using auto-transplant approaches with reduction of the skin envelope. In some cases, loss of the nipple can be addressed later using realistic tatooing.

Although breast reconstruction may be accomplished using a patient’s own muscle and fatty tissue, this complex procedure is not OUR first choice for most patients. Modern implant-based reconstruction, performed in 2 stages, can lead to excellent outcomes, that satisfy most cosmetic needs.

Mastectomy, itself, is the removal of the breast duct and lobular tissue between the skin and the underlying muscle. This removes about 90%, but never all of the breast tissue.
At the time of mastectomy, we place a smooth silicone shell expander under the pectoral muscle, and use a piece of preserved donor skin to create a hammock that holds and protects the expander. The expander is incrementally filled with saline over a period of months. We then replace the expander with a silicone gel implant that provides final form and texture.

At the first operation, our goal is to create a pocket for the ultimate implant. At the second operation, we place the implant and tailor the breast to the most natural appearance possible. Although some surgeons promote single-stage reconstruction, most of these still require later adjustment, effectively adding back a second stage.

Most breast reconstruction turns out beautifully. But, there is always a potential for adverse effects and real risks. All patients will lose sexual sensation at the nipple. Most will have a general numbness over the new breast mound. Some may feel stretching, and some will note discomfort when sleeping on their stomach. Minor adjustments of contour or nipple position may be necessary later. Fluid collections called seromas may occur, and bacterial contamination can occur leading to infection of the implant. Although we try hard to avoid these, all reconstructive surgeons face these challenges.

It is for this reason, we consider mastectomy a last, not a first choice. We work hard to avoid total breast removal. But when it is necessary, we try to provide a pathway back to health, normal contour and normal self-confidence.

We believe that more thoughtful breast cancer management leads to better cancer outcomes and better long-term patient satisfaction

Combining treatment decision-making, disease resection, and reconstruction, all in the hands of a single experienced oncologic surgeon optimizes care and maintains a laser focus on patient needs. It facilitates a patient’s journey back to better.