Simple, Radical, Nipple Sparing? Making Sense of Mastectomy (Breast Removal) Surgery

Dr Tan Yah Yuen, general surgeon at Mount Elizabeth Hospitals, answers the questions you have about mastectomies.

How do I decide on a mastectomy or lumpectomy?

A lumpectomy is a surgery to remove the cancer and tissue surrounding the tumour, but not the entire breast. There are a few considerations in choosing a mastectomy over a lumpectomy, such as the patient's emotional needs, health conditions, as well as the location of the tumour and size of a breast.

The extent or area of the breast tissue affected by the cancer, relative to the size of the whole breast, is one of the considerations. For example, removing a 2cm cancer from someone with Cup A breasts may result in significant deformity, whereas removal of the same sized tumour from a Cup C breast may not result in any obvious deformity.

Another important thing to note is that radiation treatment to the breast is usually mandatory after lumpectomy, whereas in early breast cancers, radiation treatment is not required after mastectomy.

Sometimes the surgeon may recommend oncoplastic surgery, which is the utilisation of various plastic surgical techniques or moving nearby tissues into the breast defect to reduce deformity and achieve a good external appearance of the breast.

What types are there?

Simple mastectomy involves removing the entire breast and most of the overlying skin. Radical mastectomy is removing the entire breast and overlying skin, as well as the underlying chest wall muscles, but this is rarely done nowadays.

If the woman desires immediate breast reconstruction, then as much as possible of the overlying skin (sometimes including the nipple) is preserved. This is termed skin sparing mastectomy. If the nipple is also preserved, it is called nipple sparing mastectomy.

Who is suitable for nipple/skin sparing mastectomy?

Skin/nipple sparing mastectomy is performed only if there is immediate breast reconstruction. Most of the time, it is generally up to the woman whether she would like to opt for immediate breast reconstruction. Occasionally, in more advanced cancer, the doctor may recommend delayed breast reconstruction (to be done a few months or 1 – 2 years after completion of treatment) if there is a high risk of early cancer recurrence.

Ideally, we try to preserve all the overlying skin of the breast if it is healthy. If the tumour does not involve the nipple, then the nipple can also be preserved.

What are its benefits and risks?

One benefit of mastectomy in early breast cancer is that radiation treatment usually can be omitted if the lymph nodes are not affected and the tumour is not too large/extensive.

The risk of cancer recurring in the breast is also slightly lower in mastectomy compared to lumpectomy, although this does not affect the long term survival rate of cancer patients.

It is also important to realise that the choice of mastectomy or lumpectomy does not affect the long term risk of cancer recurrence in other parts of the body such as the lymph nodes, liver, lungs or bone.

As with all surgery, there will be risks involved such as bleeding or infection but these are relatively uncommon.

For skin/nipple sparing mastectomy with immediate reconstruction, there is a slightly higher risk of poor healing, wound breakdown, or infection in women who are overweight/obese, diabetic, smokers or ex-smokers.

How long does recovery take? Will I need treatment after surgery?

A woman can return to basic daily activities in about 2 weeks, and most women return to their normal lifestyles, including going to work, in 4 – 6 weeks.  If there is immediate breast reconstruction, recovery will take a little longer.

Whether further treatment is necessary after mastectomy depends on the type and stage of the cancer. The need for systemic treatment such as chemotherapy is not changed by the type of surgery done, ie. choosing a mastectomy over lumpectomy does not mean that chemotherapy can be avoided.

If I choose not to have breast reconstruction, how will my chest look after a mastectomy?

There will be a long scar across the chest if mastectomy is performed without reconstruction. When the wounds have healed, women are encouraged to wear a silicone prosthesis (inside the bra on the operated side) to counterbalance the weight of the other breast. This will help to reduce long term strain effects on the neck and cervical spine.

What is the emotional impact after a mastectomy?

This varies widely and really depends on the patient's personality, any pre-existing psychological illness, and support from friends and family.

Most patients with a strong circle of family members and friends cope quite well while the cancer treatment is ongoing and moving on after surgery. This is especially so as immediate breast reconstruction is becoming well-accepted and commonly performed.

Some patients require a little more time and this is sometimes helped by meeting and talking with other cancer survivors who may provide practical advice and moral/emotional support. Occasionally, a referral to the social worker, psychologist or psychiatrist may be necessary for counselling and therapy.