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Mastectomy
Dalliah M. Black, MD, FACS; Katherine McElroy, BA; Henry M. Kuerer, MD, PhD, FACS
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Definitions

              • Types of mastectomy
                • Total (or simple) mastectomy: Complete excision of breast tissue without axillary lymph nodes
                  • Nipple-areolar complex traditionally removed
                  • No intentional lymph node removal
                  • Skin-sparing mastectomy: Preservation of most of skin flaps with near-complete excision of breast tissue and pectoralis fascia; performed with immediate reconstruction; ~ 10% of breast tissue remains
                  • Subcutaneous mastectomy: Removal of breast tissue through inframammary fold incision with preservation of nipple-areolar complex and pectoralis fascia
                • Nipple-sparing mastectomy: Preservation of nipple-areolar complex and skin
                  • Typical procedure for prophylactic mastectomy
                  • ↑ use over past 10-15 years for cancer treatment
                • Modified radical mastectomy (MRM): Removal of breast and pectoralis fascia with levels I and II axillary lymph node dissection (ALND)
                • Radical mastectomy: Complete excision of breast tissue, pectoralis major and minor muscles, and levels I, II, III axillary lymph nodes; not routinely done; often requires chest wall flap reconstruction
                • Extended radical mastectomy: Radical mastectomy plus excision of ipsilateral internal mammary nodal chain (not routinely done; consider for locally advanced cancer not responsive to preoperative systemic therapy with bulky adenopathy not amenable to irradiation)
                • Prophylactic mastectomy: Removal of normal breast to prevent future malignancy in high-risk patients
              • Sentinel lymph node (SLN) biopsy 
                • Performed for staging in patients with early breast cancer with no clinically suspicious nodes (physical exam or imaging)
                • Performed with lumpectomy or mastectomy; cannot be done after mastectomy
              • ALND
                • Performed when metastasis found on preoperative FNA or core biopsy, or based on SLN biopsy results
                • May be performed when SLN cannot be identified
                • Includes level I (lateral to pectoralis minor muscle) and level II (between pectoralis major and minor muscles) nodes
              • Reconstruction options
                • External prosthesis
                • Tissue expander (inflatable, temporary) to allow mastectomy flaps to heal, followed by exchange to implant (saline or silicone)
                • Autologous tissue transfers: Vascular pedicle flaps
                  • Transverse rectus abdominis myocutaneous (TRAM); latissimus dorsi (generally need additional prosthesis)
                • Autologous tissue transfers: Free flaps, defined by vascular supply
                  • Deep inferior epigastric perforator (DIEP)
                  • Superficial inferior epigastric artery (SIEA)
                  • Superior gluteal artery perforator (SGAP)
                  • Inferior gluteal artery perforator (IGAP)
              • Breast-conserving therapy (BCT): Lumpectomy followed by adjuvant radiation therapy (XRT)

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Things to Do

                            OUTCOMES

                            • Complications

                              Selected References

                              1. Craig ES et al: Outcomes of Acellular Dermal Matrix for Immediate Tissue Expander Reconstruction with Radiotherapy: A Retrospective Cohort Study. Aesthet Surg J. ePub, 2018
                              2. Khan SA et al: Readdressing the Role of Surgery of the Primary Tumor in de Novo Stage IV Breast Cancer. Cancer Treat Res. 173:73-88, 2018
                              3. Teshome M: Role of Operative Management in Stage IV Breast Cancer. Surg Clin North Am. 98(4):859-868, 2018
                              4. Tosello G et al: Breast surgery for metastatic breast cancer. Cochrane Database Syst Rev. 3:CD011276, 2018
                              5. Schaverien MV et al: Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions. Ann Surg Oncol. 24(6):1451-1453, 2017
                              6. Smith BL et al: Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 225(3):361-365, 2017
                              7. Khan SA: Surgical Management of de novo Stage IV Breast Cancer. Semin Radiat Oncol. 26(1):79-86, 2016
                              8. Helme S et al: Breast-conserving surgery in patients with Paget's disease. Br J Surg. 102(10):1167-74, 2015
                              9. Nijenhuis MV et al: Conservative surgery for multifocal/multicentric breast cancer. Breast. ePub, 2015
                              10. Murthy V et al: Nipple-sparing mastectomy in modern breast practice. Clin Anat. 26(1):56-65, 2013
                              11. Wagner JL et al: Prospective evaluation of the nipple-areola complex sparing mastectomy for risk reduction and for early-stage breast cancer. Ann Surg Oncol. 19(4):1137-44, 2012
                              12. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
                              13. Babiera G et al: Nipple-areolar complex-sparing mastectomy: feasibility, patient selection, and technique. Ann Surg Oncol. 17 Suppl 3:245-8, 2010
                              14. Sharma R et al: Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 17(11):2899-908, 2010
                              15. Brennan ME et al: Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: systematic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol. 27(33):5640-9, 2009
                              16. Gerber B et al: The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 249(3):461-8, 2009
                              17. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                              18. Choi JY et al: Aesthetic and reconstruction considerations in oncologic breast surgery. J Am Coll Surg. 202(6):943-52, 2006
                              19. Salhab M et al: Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome. Int J Clin Oncol. 11(1):51-4, 2006
                              20. Clarke M et al: Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 366(9503):2087-106, 2005
                              21. Buchholz TA et al: Controversies regarding the use of radiation after mastectomy in breast cancer. Oncologist. 7(6):539-46, 2002
                              22. Medina-Franco H et al: Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 235(6):814-9, 2002
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      • Outcomes

                                        TERMINOLOGY

                                        • Definitions

                                          • Types of mastectomy
                                            • Total (or simple) mastectomy: Complete excision of breast tissue without axillary lymph nodes
                                              • Nipple-areolar complex traditionally removed
                                              • No intentional lymph node removal
                                              • Skin-sparing mastectomy: Preservation of most of skin flaps with near-complete excision of breast tissue and pectoralis fascia; performed with immediate reconstruction; ~ 10% of breast tissue remains
                                              • Subcutaneous mastectomy: Removal of breast tissue through inframammary fold incision with preservation of nipple-areolar complex and pectoralis fascia
                                            • Nipple-sparing mastectomy: Preservation of nipple-areolar complex and skin
                                              • Typical procedure for prophylactic mastectomy
                                              • ↑ use over past 10-15 years for cancer treatment
                                            • Modified radical mastectomy (MRM): Removal of breast and pectoralis fascia with levels I and II axillary lymph node dissection (ALND)
                                            • Radical mastectomy: Complete excision of breast tissue, pectoralis major and minor muscles, and levels I, II, III axillary lymph nodes; not routinely done; often requires chest wall flap reconstruction
                                            • Extended radical mastectomy: Radical mastectomy plus excision of ipsilateral internal mammary nodal chain (not routinely done; consider for locally advanced cancer not responsive to preoperative systemic therapy with bulky adenopathy not amenable to irradiation)
                                            • Prophylactic mastectomy: Removal of normal breast to prevent future malignancy in high-risk patients
                                          • Sentinel lymph node (SLN) biopsy 
                                            • Performed for staging in patients with early breast cancer with no clinically suspicious nodes (physical exam or imaging)
                                            • Performed with lumpectomy or mastectomy; cannot be done after mastectomy
                                          • ALND
                                            • Performed when metastasis found on preoperative FNA or core biopsy, or based on SLN biopsy results
                                            • May be performed when SLN cannot be identified
                                            • Includes level I (lateral to pectoralis minor muscle) and level II (between pectoralis major and minor muscles) nodes
                                          • Reconstruction options
                                            • External prosthesis
                                            • Tissue expander (inflatable, temporary) to allow mastectomy flaps to heal, followed by exchange to implant (saline or silicone)
                                            • Autologous tissue transfers: Vascular pedicle flaps
                                              • Transverse rectus abdominis myocutaneous (TRAM); latissimus dorsi (generally need additional prosthesis)
                                            • Autologous tissue transfers: Free flaps, defined by vascular supply
                                              • Deep inferior epigastric perforator (DIEP)
                                              • Superficial inferior epigastric artery (SIEA)
                                              • Superior gluteal artery perforator (SGAP)
                                              • Inferior gluteal artery perforator (IGAP)
                                          • Breast-conserving therapy (BCT): Lumpectomy followed by adjuvant radiation therapy (XRT)

                                        PREPROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Getting Started

                                              PROCEDURE

                                              • Patient Position/Location

                                                • Procedure Steps

                                                  • Findings and Reporting

                                                    • Alternative Procedures/Therapies

                                                      POST PROCEDURE

                                                      • Things to Do

                                                        OUTCOMES

                                                        • Complications

                                                          Selected References

                                                          1. Craig ES et al: Outcomes of Acellular Dermal Matrix for Immediate Tissue Expander Reconstruction with Radiotherapy: A Retrospective Cohort Study. Aesthet Surg J. ePub, 2018
                                                          2. Khan SA et al: Readdressing the Role of Surgery of the Primary Tumor in de Novo Stage IV Breast Cancer. Cancer Treat Res. 173:73-88, 2018
                                                          3. Teshome M: Role of Operative Management in Stage IV Breast Cancer. Surg Clin North Am. 98(4):859-868, 2018
                                                          4. Tosello G et al: Breast surgery for metastatic breast cancer. Cochrane Database Syst Rev. 3:CD011276, 2018
                                                          5. Schaverien MV et al: Complications in DIEP Flap Breast Reconstruction After Mastectomy for Breast Cancer: A Prospective Cohort Study Comparing Unilateral and Bilateral Reconstructions. Ann Surg Oncol. 24(6):1451-1453, 2017
                                                          6. Smith BL et al: Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 225(3):361-365, 2017
                                                          7. Khan SA: Surgical Management of de novo Stage IV Breast Cancer. Semin Radiat Oncol. 26(1):79-86, 2016
                                                          8. Helme S et al: Breast-conserving surgery in patients with Paget's disease. Br J Surg. 102(10):1167-74, 2015
                                                          9. Nijenhuis MV et al: Conservative surgery for multifocal/multicentric breast cancer. Breast. ePub, 2015
                                                          10. Murthy V et al: Nipple-sparing mastectomy in modern breast practice. Clin Anat. 26(1):56-65, 2013
                                                          11. Wagner JL et al: Prospective evaluation of the nipple-areola complex sparing mastectomy for risk reduction and for early-stage breast cancer. Ann Surg Oncol. 19(4):1137-44, 2012
                                                          12. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
                                                          13. Babiera G et al: Nipple-areolar complex-sparing mastectomy: feasibility, patient selection, and technique. Ann Surg Oncol. 17 Suppl 3:245-8, 2010
                                                          14. Sharma R et al: Present-day locoregional control in patients with t1 or t2 breast cancer with 0 and 1 to 3 positive lymph nodes after mastectomy without radiotherapy. Ann Surg Oncol. 17(11):2899-908, 2010
                                                          15. Brennan ME et al: Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: systematic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol. 27(33):5640-9, 2009
                                                          16. Gerber B et al: The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 249(3):461-8, 2009
                                                          17. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                                                          18. Choi JY et al: Aesthetic and reconstruction considerations in oncologic breast surgery. J Am Coll Surg. 202(6):943-52, 2006
                                                          19. Salhab M et al: Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome. Int J Clin Oncol. 11(1):51-4, 2006
                                                          20. Clarke M et al: Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 366(9503):2087-106, 2005
                                                          21. Buchholz TA et al: Controversies regarding the use of radiation after mastectomy in breast cancer. Oncologist. 7(6):539-46, 2002
                                                          22. Medina-Franco H et al: Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 235(6):814-9, 2002