Skin-Sparing and Nipple-Sparing Mastectomies
What is a Skin-Sparing Mastectomy (SSM)?
A skin-sparing mastectomy, also known as breast-conserving surgery, is a way to remove breast tissue, and save the breast skin. In so doing it causes much less scarring than a traditional mastectomy. The surgeon leaves most of the breast skin, creating a natural skin envelope, or pocket, that is filled with a breast implant or with the patient’s own tissue from another part of her body. The skin-sparing techniques significantly improve the cosmetic outcome and gives the best option for reconstruction and recovery. If the nipple can be saved and has not been invaded by any cancer cells the surgeon would then perform a nipple-sparing mastectomy.
What is Nipple-Sparing Mastectomy (NSM)?
A nipple-sparing mastectomy, also known as breast-conserving surgery, is a way to remove breast tissue, and save the breast skin and nipple. In so doing it causes much less scarring than a traditional mastectomy. The nipple-sparing procedure removes cancerous breast tissue through a small incision usually around the areola area of the nipple. The surgeon leaves most of the breast skin, creating a natural skin envelope, or pocket, that is filled with a breast implant or with the patient’s own tissue from another part of her body. When performed by a well-trained surgeon, the nipple-sparing techniques significantly improve the cosmetic outcome and gives the best option for reconstruction.
40 year woman with left breast pre-cancerous dense breast tissue in upper outer quadrant.
Diseased, but noncancerous breast tissue removed and both breasts enhanced with 250 cc silicone gel implants over pectoral with small incision around areola.
43 yr. old woman with right upper breast scar and hollow after lumpectomy and radiation for stage I breast cancer.
Symmetry and contour improved by filling the depression with breast tissue using a breast pexy* or lift and the left breast was also lifted to improve symmetry and the overall appearance.
How are Skin-Sparing Mastectomy (SSM) and Nipple-Sparing Mastectomy (NSM) different than a Traditional Mastectomy?
An NSM leaves breast skin intact, and spares the nipple and/or areola while a traditional mastectomy removes much of the breast skin and nipple. Both techniques are mastectomies, they remove breast tissue and any cancer within the breast. The basic difference is preservation or removal of breast skin which includes the nipple and areola. Skin and Nipple-sparing techniques offer many advantages over a traditional approach.
44 yr old woman after complete removal of Breast tissue for a stage II cancer, but preservation of skin and nipple (NSM). Skin tailored with keyhole pattern and volume replaced with silicone implant, nipples are reconstructed.
52 yr old woman treated with bilateral traditional mastectomy (removal of breast tissue and skin) stage I breast cancer.
Is a Skin-Sparing Mastectomy (SSM) or a Nipple-Sparing Mastectomy (NSM) safe?
A large body of evidence, from prestigious institutions, shows that women who undergo SSM and NSM have the same risk of cancer recurrence as those with traditional mastectomy.
Is a Skin-Sparing Mastectomy (SSM) or Nipple-Sparing Mastectomy (NSM) better than a Traditional Mastectomy?
Virtually all studies agree the cosmetic appearance of the breast is better. By using a nipple-sparing approach to remove breast tissue the skin is not marred by large horizontal scars and shape problems produced by traditional mastectomies.
Pre-op breast appearance.
NSM with immediate implant and nipple reconstruction.
Modified radical mastectomy and radiation.
Delayed expander reconstruction and silicone implant under pectoralis muscle, left nipple reconstructed.
What is the difference between Breast Skin and Breast Tissue?
Breast skin is the external skin you feel and see, including the nipple and areola. Breast tissue is internal, consisting of: fat, milk glands, connective tissue, and ducts. Ducts are small tubes that connect the glands to the nipple. These ducts are the source of most breast cancers.
"External" breast skin.
Illustration of breast "internal tissue."
Breast Anatomy 101
- skin; the external skin of the breast is shaped in a characteristic fashion due to the growth of the breast tissue within as a woman develops. Over time, the skin stretches in response to pregnancy, weight changes, gravity, and age.
- nipple and areola; the nipple is a specialized piece of skin that provides a outlet for 12 to 15 tubes or ducts that deliver milk to the surface. The surrounding areola is just pigmented skin; the surface is knobby due to small lubricating glands. A thin layer of muscle just below the skin contracts the nipple and areola.
- fat; fat or adipose tissue makes up a lot of the breast volume. It gives the breast its soft texture.
- connective tissue; the fibrous tissue holds things together. The small nerves and blood vessels are held in a delicate network of fibrous tissue. The gradual stretch of these fibers causes the skin to stretch and the breast droops.
- glands; the milk glands sit idle as tiny nests of cells within the breast until stimulated by pregnancy or nursing to produce milk. This is the only type of breast tissue absent in men.
- ducts; these tiny tubes course throughout the breast from the nests of milk glands and gradually coalesce into 12-15 larger ducts which end at the nipple. Most breast cancers are ductile, they begin from duct cells. Since men have ducts, though no glands, they can and do get breast cancer too.
- lymph nodes; these are small jelly bean size tissues found throughout the body. They are part of the lymph system that cleans and filters infection, disease and even cancer. They are not within the breast but nearby, in the underarm and inside the chest.
- rib cage; the breast sits atop the rib cage. The pectoral muscle is a large, flat muscle which lives over the rib cage but underneath and separate from the breast.
- breast cancer; most breast cancers begin deep in the breast tissue itself from the duct cells.
How is a Skin-Sparing Mastectomy or Nipple-Sparing Mastectomy performed?
A nipple-sparing mastectomy can be performed through a variety of surgical incisions.
The simplest is an incision placed at the edge of the areola.
For larger breasts a longer incision may be needed however. The incision is extended from the nipple in lollipop or upside down "T" shape.
The key to the best cosmetic result is to remove as little breast skin as possible! This way the Plastic surgeon responsible for reconstructing the breast only has to contend with replacing the breast volume, not the skin envelope.
What is done during surgery with a Skin-Sparing or Nipple-Sparing Mastectomy?
Once the incision is made, usually by the general surgeon, the cancerous breast tissue is cut out or excised. The illustration shows the steps involved in the surgery.
Once the cancerous tissue has been removed (see Fig. 2), depending on the space created by the loss of breast tissue (see Fig. 4), the space can be replaced with a breast implant or muscle and fat from your own body (see Fig. 5). If the second option is used, the muscle and fat usually comes from the lower abdomen, this procedure is called a TRAM Flap (Option 2).
An implant when used is typically placed below the pectoral muscle especially if the area needs radiation treatment but may be placed above the muscle if the skin is thick enough. (see Breast Anatomy 101).
Nipple and Areola Concerns in Skin-Sparing and Nipple-Sparing Mastectomies
A critical issue is whether to preserve or sacrifice the nipple or nipple and areola. If the cancer does not involve the nipple or areola then nipple preservation may be possible, and should be discussed with the surgeon(s) and oncologist. The nipple which contains duct tissue should be considered separately from areola tissue which is only modified, darker skin. If the nipple must be removed there are options to reconstruct the nipple using your own skin.
How is a Traditional Mastectomy performed?
A traditional mastectomy (“TM”) makes two long horizontal incisions across the front of the breast. Once the breast tissue is removed, the breast skin is closed as a straight line leaving a typical scar across the chest that is the width of the breast. When the volume of the breast is replaced with an implant the shape is typically more bowl shaped than breast shaped due to loss of this skin.
The key to improved cosmetic results is sparing the skin and if possible, the nipple.