This document discusses skin sparing mastectomy (SSM) and nipple sparing mastectomy (NSM). It provides details on the anatomy of the breast and history of breast cancer treatment. SSM aims to remove all breast tissue while preserving the skin and NAC. NSM further preserves the nipple. Selection criteria for NSM include small tumor size and distance from NAC. Outcomes of SSM and NSM are similar to MRM with acceptable morbidity. Complication rates of NSM include nipple necrosis around 7% and occult nipple involvement around 10%. Frozen section of subareolar tissue during NSM helps guide decision for NAC removal. Overall, SSM and NSM provide improved cosmetic

1. PROF.S.SUBBIAH et al.
Skin sparing and
Nipple sparing
mastectomy
Department of Surgical Oncology
Centre for Oncology
GRH,Royapettah

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Breasts & Women
• Breasts - not considered as parts of body alone
• Symbol of femininity and motherhood
• Self confidence
• Loss of breast  change in social behavior,
eating behavior, depression

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Anatomy of breast
• Modified sweat gland
• Within the superficial fascia of the anterior
chest wall
• Second rib to sixth or seventh rib
• Sternal border medially to the midaxillary line
laterally

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Blood supply to breast

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Anatomy of nipple
• Fat free area under NAC
• 15–20 lactiferous ducts converge in a radial direction on the tip of nipple
• The dermis of the skin merges with superficial fascia which envelops the
parenchyma of the breast
• Colour of NAC - by blood vessels lying close to surface in long dermal
papillae
• At puberty and with each pregnancy - increase in the melanin content of
the basal cells
• Subareolar plexus of lymphatics

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History of breast cancer
• 3600 yrs ago
• No treatment for 1700 yrs
• Hippocrates - not to excise - in 400 BC
• Galen - Black bile theory or humoral theory
Coagulam of black bile
• Escharotomy - 1st century AD
• Guillotine approach - Renaissance period
• Mastectomy - 17th and 18th century

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Evolution of concepts in breast cancer
treatment
No
treatment
Escharotomy
Guillotine
Radical
mastectomy
Modified
radical
mastectomy BCS
SSM
NSM

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Radical mastectomy
• William Steward Halsted - in 1882
• 0% perioperative mortality
• 3 yr local recurrence rate - 6 %
• 3 yr locoregional recurrence rate - 22%
• 5 yr survival 45% (twice when
compared to untreated patients)
• Willie Mayer

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Extended radical mastectomy
• Removal of more regional lymph nodes
• Supraclavicular, internal mammary &
mediastinal nodes
• Increased morbidity and mortality
• Abandoned

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Modified radical mastectomy
• Patey and Dyson - 1940
• Preservation of pectoralis major
• 50% patients needed skin grafting
• No difference in outcome
• Conclusion : Without systemic treatment,
mortality is hardly affected by type and extent of
local treatment
• Because in a high percentage of patients, the
disease is systemic on presentation

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Modified radical mastectomy
• Auchincloss in 1970 - horizontal incision
• Madden - vertical incision
• Preservation of both pectoral muscles
• Equally effective
• Less morbidity
• Gold standard technique

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Breast conserving surgery
• Fisher - disease was systemic from beginning
- microscopic metastases were present
in most patients
- impact of extensive surgery on survival
was minimal
• BCS - in 1990
• Breast conserving surgery + radiotherapy was
equally as effective as mastectomy

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MRM --> Breast conservation
• One size fits all concept - proven wrong
• Now Tailor made approach for each individual
patients

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Skin sparing mastectomy
• Toth and Lambert - 1991
• Initially major concern regarding the amount of
residual breast tissue remaining on the longer skin
flaps, inframammary fold, and axillary tail
• Barton et al disproved it
• Well-planned incisions
• To allow immediate reconstruction
• Better breast contour and cosmetic results

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Skin sparing mastectomy

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Skin sparing mastectomy - 4 types
• Type 1 - only nipple areola complex removed
• Type 2 - NAC is removed along with skin overlying the
tumour & biopsy site as one specimen
• Type 3 - Similar to type 2 but resected separately leaving
intact tissue in between
• Type 4 - NAC is removed along with certain amount of
skin using wise pattern breast reduction skin incision

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Type -1 Type - 4

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Skin sparing mastectomy
• Indications :
Just like any other mastectomy
• Small and medium size breasts - Types 1 to 3 SSM
• Large ptotic breasts - Type 4 SSM
• Absolute contraindications :
1. Skin involvement by the tumour
2. Inflammatory carcinoma

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Results of SSM
• Recurrence after SSM - 3.8% to 10.4%
For NSSM - 1.7% to 11.5%
• No statistically significant difference between
the two groups
• Skin flap ischemia and necrosis - 11% (same as
NSSM)

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SSM - Benefits
• Reduced postmastectomy deformity and
improved breast shape
• Scars are better and reduced
• Need for extensive tissue expansion and for
myocutaneous flaps is minimal
• Immediate reconstruction has a beneficial
impact on patient’s psychology

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Nipple sparing mastectomy
• Freeman in 1962 - for benign diseases
• Total skin sparing mastectomy
• Patient's dissatisfaction regarding shape of the
reconstructed NAC, lack of projection and color
match --> concept of NSM

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NSM - Criteria for patient selection
1. Prophylactic mastectomy
2. Management of Cancer
Size of tumour <3 cm
Distance from nipple areola complex >2-4 cm
No bloody nipple discharge
Clinically no involvement of nipple areola
Frozen section from subareolar area negative
Not centrally located tumours

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NSM - Criteria for patient selection
• Debatable
Lymph node status
Preoperative chemotherapy /radiotherapy
• Not advisable based on tumour biology
ER(-), PR (-), LVI (+)
• Absolute contraindications
1. Skin involvement by the tumour
2. Inflammatory carcinoma

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Rare indications of NSM
1. Phyllode tumours
2. Stromal hyperplasia
3. Previous silicone injection
4. Dense breasts
5. Mastodynia

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Occult nipple involvement
Overall - 25% (De Vita - 58%)
By this selection criteria - 10%

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NSM - Incisions

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NSM - Technique
• Dermis and epidermis of the nipple are
left behind
• But all the ducts are removed from the
lumen of the nipple
• Distal part of the ducts is sent for frozen
section
• If it is positive  convert to SSM by
removing the NAC

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Subareolar frozen section
• Sensitivity - 91%
• Specificity - 98%
• False negative rate - 8.7%
• Occult carcinoma in retained NAC - 1.2 to 5.9%
- Most often DCIS
• Debate regarding role of Frozen section - as it
distorts the specimen
• Some centers - NAC managed in second stage if HPE
is positive

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• 48 studies
• 6615 cases

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NSM - outcomes
• Locoregional recurrence rate - 1.8%
• Distant metastasis rate - 2.2 %
• Most reconstructions - Implant and/or tissue expander
• Only 13.8% used autologous tissue
• Overall pooled complication rate - 22%
Two-stage reconstruction (expander to implant) - 52.8%
One stage reconstruction (direct to implant) - 16.7%
Autologous reconstruction - 23.7 %

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Nipple necrosis
• Nipple necrosis rate - 7%
Before 2010 - 10.22%
After 2010 - 6.46%
• Based on incision types
Highest in transareolar - 81.82%
Least in previous mastopexy incision - 4.76%

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Erectile function & sensation of NAC
• Nerves traveling along the chest wall from lateral
edge of sternum to medial aspect of NAC
• Wagner et al
• Measured nipple erection preoperatively and at 6
& 12 mon after NSM
• Nipple erection was preserved in the majority of
patients

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NSM/SSM/MRM
• Meta analysis
• 20 studies
• 5594 patients
• No significant difference in DFS, OS and LRR

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Two stage NSM
1. NAC is detached from underlying lactiferous
glands through a periareolar incision
2. NSM after 2-3 weeks
• Subareolar biopsy is performed during the
first operation
• Drawbacks of frozen section are eliminated

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ELIOT
• Electron beam intraoperative radiotherapy
• Petit and Veronasi
• Radiosurgical treatment combining
subcutaneous mastectomy with IORT
• Total necrosis of NAC - 3.5%
• Partial necrosis - 5.5%
• Prosthesis removal - 4.3%
• Same result as post-op RT

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Take home message
• Tailor made approach for breast cancer
• Reconstruction considered as an integral part of breast
cancer surgeries
• SSM and NSM needs careful selection of patients
• Similar oncological outcome with acceptable morbidity
for SSM and NSM compared to MRM
• NSM should include frozen section of subareolar area

38. PROF.S.SUBBIAH et al.
Thank you