How to Give Yourself the Best Chance for a Normal Breast Shape After Mastectomy

By Constance M. Chen, MD, MPH

Many people who have seen a woman’s chest after mastectomy have been exposed to the bold horizontal line that marks the spot where the breast existed before it was amputated. The preoperative markings for a traditional mastectomy look like an eye drawn on the breast to indicate the area of skin that will be cut out.

Removing this football-shaped section of skin permanently flattens the three-dimensional shape of the breast – even after breast reconstruction, especially if the breast reconstruction is performed using breast implants. Although this is the design of a traditional mastectomy, it is possible to preserve the shape of a normal breast with a little bit of foresight, By using plastic surgery techniques, the breast surgeon can do her mastectomy through a different incision that preserves the skin envelope of the breast so that a natural breast shape with projection is maintained after breast reconstruction.

The most obvious way to preserve the skin envelope is to preserve the nipple-areola complex,” says Dr. Chen. If the patient’s tumor is not involved with the nipple, then she may be a candidate for a nipple-sparing mastectomy. If a woman does not have breast cancer, and she is undergoing mastectomy for prophylaxis, then there is no oncological advantage for her to remove her nipple. Likewise, if the woman’s tumor is located far from the nipple-areola complex, then multiple studies have demonstrated that saving the nipple is safe.

In a nipple-sparing mastectomy, incisions can be placed in different areas of the breast depending on the woman’s original breast shape. If a woman has had other breast surgeries – such as breast biopsies or lumpectomies – then it may also be possible to incorporate the previous scars into the mastectomy. For example, if she has a scar on the side of her breast, it may be possible to incorporate this scar to perform the mastectomy.The plastic surgeon can then figure out how to obtain the best breast shape using the scars that already exist.

If a woman is not a candidate for a nipple-sparing mastectomy, then it is still possible to preserve the skin envelope and ultimate breast shape by carefully designing the incision prior to performing the mastectomy. Importantly, a traditional mastectomy that removes an eye-shaped area of skin will flatten and distort the breast shape, even if it only leaves a small, short horizontal line. The horizontal scar across the dome of the breast always distorts the shape and flattens the breast. In order to preserve the breast shape, the breast surgeon and the plastic surgeon must work together to maintain the original contours of the breast.

When a nipple-sparing mastectomy is not possible for oncological reasons, the easiest way to preserve the skin envelope is to use a periareolar incision with a vertical extension. The periareolar incision cuts out the nipple-areola complex as a circle, and then a vertical line is made from the bottom of the areola extended to the inframammary fold. This incision should give the breast surgeon plenty of access to remove the entire breast.

In the cases where a woman is not a candidate for a nipple-sparing mastectomy, then she may also be able to undergo a skin-sparing mastectomy via a periareolar incision only. In this operation, the entire mastectomy is performed through a periareolar incision without a vertical or horizontal incision. Since a complete mastectomy must be performed through the circular cutout that is left where the nipple-areola complex used to be, the areola must be large enough for the breast surgeon to be able to gain access to the entire breast.

The key is to find a breast surgeon and a plastic surgeon who care enough about the final result to preserve the original shape of the breast.. A traditional mastectomy that removes a large almond-shaped area of skin is the fallback of most breast surgeons, and most breast surgeons have only been trained in traditional mastectomy techniques. Most have not been trained to preserve the contours of the breast resulting in a more natural shape. Sometimes a breast surgeon will call their mastectomy “skin-sparing” because the horizontal line is short, but if the mastectomy leaves the telltale horizontal scar where the breast used to be, then it is basically a traditional non-skin-sparing mastectomy.

Women who want to optimize the ultimate appearance and shape of their breast after mastectomy and breast reconstruction must take control of their bodies and do their homework in advance. The simple decision of what incision is used to perform a mastectomy can affect the final outcome of a woman’s post-mastectomy breast reconstruction forever.

Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. www.constancechenmd.com