A skin-sparing mastectomy is a refined technique that allows women who choose immediate reconstruction some of the best possible aesthetic outcomes. This requires the cosmetic surgeon to guide the breast surgeon in incision patterns for the mastectomy. These are typically in a concentric pattern around the nipple/areola complex, and may possibly extend vertically from the bottom of the areola to just above the breast crease or laterally from the side of the areola toward the axilla (underarm). The breast or cancer surgeon then removes the underlying tissue leaving the overlying skin intact. The nipple and areola may or may not be removed. The cosmetic surgeon then performs the immediate reconstruction. This is done using a flap from the abdomen, back, buttock, or thigh to provide the tissue bulk needed to reconstruct the breast. For thin women who may not be ideal candidates for flap surgery, skinsparing mastectomy with immediate reconstruction using a breast implant provides a good option. For nearly all women, it reduces the visible scars on the breast, and provides some of the most pleasing aesthetic outcomes.
Patient selection is the key in determining whether lumpectomy, skin-sparing mastectomy, or mastectomy is best for you.Two key factors in patient selection include:
• The size, location, and type of tumor or cancer present, and the best possible treatment to ensure your health
• The cosmetic result of certain procedures and your desire for reconstruction
If your goals reach beyond treating your breast cancer, the cosmetic result of your procedure and any plan for reconstruction require the cooperation and involvement of your breast surgeon, oncologist, and your plastic surgeon. Your health must be the primary factor in determining any form of treatment. You may, in fact, be given the choice of procedures. Make your decision based on your personal goals for health, your personal and realistic goals for reconstruction, and the advice of your cosmetic surgeon. cosmetic surgeons who are experienced in breast reconstruction work closely with breast cancer surgeons. They fully understand and uphold your health considerations before making a prescription for reconstruction.
There are women who elect to undergo mastectomy as a means to prevent breast cancer. Preventative (or prophylactic) mastectomy is the removal of one or both breasts to prevent breast cancer from developing or to reduce a woman’s chance of developing breast cancer. Reasons why a woman may choose preventative mastectomy, or have the procedure recommended to her, include:
• A strong family history of breast cancer, namely, those forms of breast cancer known to be hereditary traits or where close relatives have died from breast cancer before the age of 50
• A positive test that demonstrates the woman carries the BRCA1 or BRCA2 genes
• An invasive form of breast cancer on the opposite breast
• Prior invasive forms of cancer near the breast area or in the axilla (underarm area)
• A very large number of breast calcifications and very dense breast tissue
A preventative mastectomy can reduce a woman’s chances of developing breast cancer, but nothing can completely eliminate the risk for breast cancer. Preventative mastectomy does offer additional advantages. Preventative mastectomy allows a woman to plan for her surgery.With ample time to plan, she may feel less stressed, and therefore have plenty of time to learn about and weigh her reconstructive options. There are alternatives to preventative mastectomy, and these should be carefully discussed with your personal physician and a cancer specialist. These include: medications such as tamoxifen; close monitoring of breast health and changes by the woman and her physician; and potential alterations in diet, alcohol consumption, and tobacco use. The use of hormone replacement therapy and its role in the development of breast cancer is highly controversial, and should be discussed with your personal physician or cancer specialist.
To date, no studies reveal whether preventative mastectomy or any of the available alternatives offer higher success rates and satisfaction for women who are at high risk for developing breast cancer. It is important to understand that prophylactic mastectomy is a very serious decision. The outcomes are permanent, there is no guarantee that you will not develop any form of cancer, and the reconstructed breast will never be the same as the natural breast. A study published in the January 14, 1999 issue of the New England Journal of Medicine was based on a retrospective study of 693 women who had prophylactic mastectomies between 1960 and 1993 at the Mayo Clinic. The study concluded that in women with a high risk of developing breast cancer, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90%.
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1. Breast reconstruction and general types of free flaps
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