Making decisions about reconstructive breast surgery is hard to do when you are still reeling from your cancer diagnosis. But the fact is that looking into your choices for reconstruction as soon as possible may mean you have more options. Skin-sparing mastectomy (SSM) is one procedure you will definitely want to discuss with your oncologist and a specialist in plastic surgery. Breast cancer treatments that involve radiation can impact the elasticity, texture, and overall health of your skin in ways that may affect the reconstruction process. It’s important for your team of care providers to communicate and collaborate so you know about all your options from the start.
Why Might a Patient Choose SSM Over a Lumpectomy?
Women with smaller breasts or a large lump of cancerous tissue that must be removed sometimes opt for a skin-sparing mastectomy instead of lumpectomy. Reasons for this decision may include a desire to avoid having subsequent radiation therapy. Or, the patient may feel that there would be too little breast tissue remaining after the procedure. In that case, reconstruction would be required anyway to replace the lost volume and restore a normal appearance. Some women decide to have a prophylactic (preventive) mastectomy on the unaffected breast as well. This can minimize the risk of developing cancer on that side later on and reduce patient anxiety.
These decisions about whether mastectomy is a suitable treatment to replace a lumpectomy must take into account several factors including:
- The type of cancer present (e.g., malignant or non-malignant)
- Where it is located in the breast (breast cancer usually doesn’t affect the skin)
- The size of any tumor(s)
- The potential for recurrence
Skin-Sparing Mastectomy vs. Traditional Mastectomy
The SSM procedure works best when the skin on the breasts is in good condition. When that’s the case, skin sparing mastectomy generally delivers a more natural looking result than a traditional mastectomy (followed by reconstructive breast surgery that involves tissue expansion and flap procedures). A standard mastectomy excises most of the breast skin and leaves horizontal scars across the chest. These incision lines often appear puckered as the skin contracts unevenly during healing. Subsequent reconstruction adds more scars on the breasts and on areas where donor skin is removed. Plus, it can be challenging to match skin grafts from other areas of the body with the surrounding skin.
With a skin sparing mastectomy, the original skin is left in place and the breast tissue underneath is removed. The scarring may be camouflaged by the tattooed pigmentation around the reconstructed areola. If the cancerous lump is small and not located near the nipple and areola, these structures may be spared as well. When the areola is spared, the scar may be located just around the bottom edge of the areola or in the crease where the breast meets the ribcage. For women with larger breasts, an additional incision from the areola down to the crease (a lollipop incision) may be needed as well.
These scars are similar to those you would see with a breast reduction, breast lift, or similar plastic surgery. Breast reconstruction scars from this procedure will be visible. However, they are not as extensive as scars left by a traditional mastectomy and reconstruction operations. The SSM approach works best when reconstruction is done immediately after the cancer removal as part of the same procedure. The spared skin pocket can be left “empty” for later reconstruction if radiation treatment is planned, but this usually results in a less successful outcome. The breast skin will shrink and may toughen and scar as a result of radiation. This may necessitate tissue expansion or skin grafting to create enough room for restoring breast volume during reconstruction.
Does Sparing the Skin Increase Cancer Recurrence Risk?
At this time, the most accurate data available is from a 2010 study published in the Annals of Surgery: “Comparison of Skin-Sparing Mastectomy vs. Non-Skin-Sparing Mastectomy for Breast Cancer: A Meta-Analysis of Observational Studies”. These researchers analyzed recurrence rates for more than 3400 patients with stage 1-3 breast cancer. The results indicate that the recurrence rate for local tumors is about 5% for both traditional and skin-sparing mastectomy. The only way to get more accurate statistics would be to carry out a trial in which patients were randomly assigned to a traditional or skin-sparing mastectomy. Since most women have a preference about their reconstruction procedure, such a study is unlikely to occur. So, following up with regular checkups after any type of breast reconstruction surgery is your safest bet for continued health.
SSM Can Be Done With or Without Implants
A skin-sparing mastectomy can be combined with a flap reconstruction that involves transferring fatty tissue and muscle from another area of the body to fill out the breast. The TRAM flap procedure used during some breast reconstruction surgeries acts as a tummy tuck. This can be an attractive option for women who want a full body makeover to restore their self esteem as a cancer survivor. However, some women prefer to use implants and avoid the potential complications of abdominal surgery. This may be the best option for women who are thin and don’t have enough tissue to spare for grafting. Patients may also prefer the look of implants – especially if they are having both breasts reconstructed or if they want to go up a size from their original breasts.