Archives for April 2011

**We are delighted to introduce our guest blogger, Dr. Paul Baron, MD F.A.C.S of Cancer Specialists of Charleston. Dr. Baron shares with us his insight on who can have a skin-sparing and nipple-sparing mastectomy and why.

See below for Dr. Baron’s guest post:

The best cosmetic results from breast reconstruction are clearly in patients who still keep much of the original skin of the breast. It leads to a more normal shape, appearance, and texture. In the past, the fear was that the cancer overlying a breast tumor needed to be removed; even if the cancer was far away from the skin in the back of the breast. All mastectomies were done with a large horizontal elliptical incision that removed a large segment of skin extending from the sternum to the lateral chest. The nipple and areola were removed at the same time as there was concern that the cancer could march up the ducts and be left behind if the nipple is left behind.  As a result, there was not enough pliable tissue to allow placement of an implant or tissue flap under the skin. The reconstruction could only be done by stretching the skin first with a tissue expander or leaving a large island of skin with the attached underlying flap of tissue (TRAM, latissimus, DIEP, or GAP). The result was a very unnatural breast reconstruction.

We now know that in most mastectomies, virtually all the skin overlying the breast can be left behind as long as the cancer is not immediately underneath it. In this case, we still remove a small patch of overlying skin. The most common incision for a skin-sparing mastectomy goes just around the areola with an extension inferiorly (kind of like a tennis racket shape), or a horizontal ellipse that is half the distance of the more traditional mastectomy incision. The resulting reconstruction is more natural in appearance as there is a very small scar and often no visible island of skin.

Another approach gaining in popularity is a nipple-sparing mastectomy. In this case, the entire breast is removed through an incision that completely leaves the nipple and areola intact. There are many ways to make this incision. Clearly these patients have the most normal appearing breast reconstruction. Also, to relieve the concern of cancer cells being left in the ducts, we actually core out the ducts as they enter the nipple. The shell of the nipple is left behind and as a result, often looks better than the nipple reconstruction.

We will not perform a nipple-sparing mastectomy if the cancer is close to the nipple. Also, if a patient had a prior mastectomy in which the nipple and areola were removed with one breast, we will usually remove the contra lateral nipple at the time of prophylactic mastectomy so the reconstruction result is symmetrical. It should also be pointed out that in most cases in which the nipple is left behind, it does not have normal sensation. It can have sensation to touch and temperature, but lose erotic sensation.

We have made huge strides in breast cancer surgery. For patients requiring or choosing mastectomy, the final reconstructed version can have a natural reconstruction as a result of usually leaving the skin behind as part of a skin-sparing mastectomy. We have improved this even more by performing nipple-sparing mastectomies. The optimum result is when the breast surgeon works as a team with the plastic surgeon in planning the type of mastectomy from a cancer point of view, and the orientation of the incision from a cosmetic point of view.

About Dr. Paul Baron:

Dr. Baron is Board Certified in General Surgery and completed a Surgical Oncology Fellowship at Memorial Sloan-Kettering Cancer Center in New York City. He is a graduate from the Boston University Six-Year Medical Program. Dr. Baron subsequently completed a residency in General Surgery at the Medical College of Virginia.

Cancer Specialists of Charleston – www.cancerspecialistsofcharleston.com