Sensation Preserving Mastectomies
Sensation Preserving Mastectomies
Sensation Preserving Mastectomies

Who is a Candidate for Sensation-Preserving Mastectomies?

Sensation-preserving mastectomies can be offered to those who are diagnosed with breast cancer, those who are at high risk for developing future breast cancer, and those who are considering a prophylactic mastectomy. A sensation-preserving mastectomy involves saving the nerves when “oncologically safe.” This means the nerves need to either run in the fatty tissue layer beneath the skin where they can avoid being cut or reconstructed after being cut during the mastectomy, which is the case if the nerves run through the breast tissue instead of staying in the fatty tissue layer.

Each person’s situation is unique, so to determine if you are a candidate for a sensation-reserving/nipple sparing mastectomy, it is essential to undergo an evaluation. The results of your evaluation will help you learn if the procedure is right for you and what the best choices are for your reconstruction, so you and your surgeon can come up with a final surgical plan.

Who is a Candidate for Sensation Preserving Mastectomy

Sensation-preserving mastectomies can be offered to those who are diagnosed with breast cancer, those who are at high risk for developing future breast cancer, and those who are considering a prophylactic mastectomy.

Why is This Procedure so Critical and Unique?

A mastectomy is one of the most effective ways to reduce the risk of breast cancer, but something that isn’t talked about enough is that the procedure almost always results in the patient having little, if any, sensation in their breast skin or nipple skin afterwards. The reason this happens is because the nerves to the breast skin and nipple travel through the breast tissue, and these nerves get cut during a traditional mastectomy.

Once these nerves are cut, breast and nipple numbness occur and, in some cases, women may even suffer painful sensations at the ends of the cut nerve. Because of the variable nerve anatomy in the breasts, there are some women who may get lucky and have sensation gradually return over time without active preservation of nerves during surgery, but most women will not.

This type of mastectomy, which was developed by Drs. Anne and Ziv Peled, utilizes an innovative technique that preserves and grafts the nerves that are typically injured during a mastectomy surgery. By undergoing a sensation-preserving mastectomy, a woman will have a significantly greater opportunity to feel like herself again. And perhaps even more importantly, she won’t have to endure a lifetime reminder of her breast cancer surgery because of constant chest numbness.

Why is this Procedure so Critical and Unique?

A mastectomy is one of the most effective ways to reduce the risk of breast cancer, but something that isn’t talked about enough is that the procedure almost always results in the patient having little, if any, sensation in their breast skin or nipple skin afterwards.

What are the Results?

According to research conducted by Drs. Anne and Ziv Peled, over 80% of women who undergo sensation-preserving mastectomies have sensation that is similar to what they had before surgery. Many women even report that they often forget they had a mastectomy and reconstruction surgery because their reconstructed breasts feel so much like their breasts prior to surgery.

There are four common incision types for nipple-sparing/sensation-preserving mastectomies, all of which allow scars to heal well and fade over time: inframammary fold (underneath the breast), peri-areolar (around part of the areola), lateral (from the side of the areola out towards the side of the breast), and inferior vertical (from the bottom of the areola down towards the bottom of the breast).

For most patients, a sensation-preserving double mastectomy and implant reconstruction takes about three to four hours of surgery, with an overnight stay in the hospital or surgery center. As for post-surgical recovery, most women return to their daily lives and activities within two weeks, with complete recovery in most cases in four to six weeks.

What are the results?

According to research conducted by Drs. Anne and Ziv Peled, over 80% of women who undergo sensation-preserving mastectomies have sensation that is similar to what they had before surgery.

Where can I get this done?

Since this is a relatively new procedure, not every plastic surgeon offers this service. However, sensation-preserving mastectomies are fast-gaining in popularity and as a result more and more surgeons are utilizing the technique. If you are diagnosed with breast cancer or are interested in having a prophylactic mastectomy performed because it runs in your family, then you should ask your surgeon if they have experience with nerve sparing mastectomy and reconstruction.

Where can I get this done?

Since this is a relatively new procedure, not every plastic surgeon offers this service.

Mastectomy Considerations Preserving the Nipple

In the past, mastectomies involved the removal of most of the chest skin and even some of the chest muscles, but modern mastectomy techniques are much less invasive. Today, most mastectomies performed are either skin-sparing, where all the breast skin except for the nipple and areola is saved, or nipple-sparing, where all of the breast skin including the nipple and areola skin is saved.

When a modern mastectomy is performed with breast reconstruction, it results in the reconstructed breast looking more natural and more like the breast before mastectomy. And when sensation-preserving techniques are employed during the reconstruction, the reconstructed breast not only looks like the breast before the mastectomy, it also feels like it.

Mastectomy Considerations Preserving the Nipple

In the past, mastectomies involved the removal of most of the chest skin and even some of the chest muscles, but modern mastectomy techniques are much less invasive.

What Will the Incisions Look Like?
Will There Be Scarring?

INFRAMMARY FOLD

INFERIOR VERTICAL

LATERAL

PERIAREOLAR

Reconstructive Procedures

To ensure the reconstructed breast looks natural, one of two different reconstructive procedures will be used to restore the breast’s appearance, either implant reconstruction or flap reconstruction, which uses your own tissue for breast reconstruction instead of implants. Between 80% and 90% of women choose implant reconstruction because flap reconstruction is a much more invasive type of surgery and as a result, it requires a much longer procedure time and hospitalization, as well as extensive recovery after surgery.

The main benefit of implant-based reconstruction is that no large additional scars outside of the breast are needed and the post-operative recovery is often easier, with a typical two- to four-week recovery period. Implant-based reconstruction for mastectomy can be done in either one stage (direct-to-implant), where a permanent implant is placed at the time of mastectomy, or in two stages, where a temporary implant called an expander is placed at the first stage and switched to a permanent implant at the second stage.

The decision on which approach to use is based on pre-mastectomy breast size and shape, patient goals, and intra-operative assessment following mastectomy. Implant-based reconstruction may also include fat grafting at the second stage of reconstruction to help give the reconstructed breast as natural an appearance as possible.

Reconstructive Procedures

To ensure the reconstructed breast looks natural, one of two different reconstructive procedures will be used to restore the breast’s appearance, either implant reconstruction or flap reconstruction, which uses your own tissue for breast reconstruction instead of implants.

Direct-to-Implant Reconstruction

Implant-based breast reconstruction has evolved to the point that two-stage reconstruction with an initial expander is often no longer necessary. Many plastic surgeons are now realizing that selected patients may be able to have direct-to-implant reconstruction surgeries, in which an implant is placed at the time of mastectomy. This is also called a “One and Done” mastectomy. The benefits of this approach are that women can avoid the need for a second surgery and get to their final reconstructive outcome more quickly.

Direct-to-Implant Reconstruction

Implant-based breast reconstruction has evolved to the point that two-stage reconstruction with an initial expander is often no longer necessary.

Choosing Your Implant Type

When choosing your breast implant type, you have two options – an implant filled with saline or silicone. Both silicone and saline implants are available in round and teardrop shapes, and they both come in different levels of projection across different volumes. Of the two, silicone implants are softer to the touch and are considered by many women to feel more like natural breasts, but saline implants are safer in cases of rupture because the saline can be safely absorbed by the body. Ultimately, it is up to you and your doctor to choose which type of implant will work best for your unique situation and whether the implant will be inserted over or under the muscle.

Choosing your Implant Type

When choosing your breast implant type, you have two options – an implant filled with saline or silicone.

Over or-Under-The-Muscle

Pros: Over-the-muscle breast implants create a more natural-appearing upper part of the breast. This type of implant also typically results in less chronic pain and functional issues because it doesn’t require the pectoralis muscle to be cut. Over the muscle implants tend to work best for patients who have undergone prior radiation or are expected to have post-mastectomy radiation because this type provides better breast shape and symmetry.

Cons: When an implant is inserted over the muscle implants, rippling can sometimes be more visible along the top of the breast, and any mastectomy skin flap irregularities can also be more visible. Plus, not all plastic surgeons may not offer this technique as it depends largely on their experience and training.

Pros: Under-the-muscle implants are the most common type of breast implant because this is the type that most plastic surgeons have been trained to perform. This type of procedure produces less rippling or visible edges along the top of the breast, and it may be potentially better for patients concerned about breast cancer recurrence because it is more accommodating to screening techniques.

Cons: With under-the-muscle implants, it is more common for the patient to experience short- and even long-term pain in some cases. It’s also not uncommon for a patient to have “hyper animation deformity,” which is excessive movement of the implants along the top of the breast with any pectoralis movement. Lastly, because these implants are often displaced towards the armpits/sides, they can sometimes appear flatter along the top.

Fat Grafting

Fat grafting is a process that is often performed as a part of a post-mastectomy breast reconstruction. It is most done during the second stage of reconstruction, and it involves liposuction of fat from the abdomen or thighs. Once the fat is collected, it is specially processed in the operating room to get it ready for transfer and then carefully injected throughout the mastectomy skin flap and sometimes the chest wall muscles. The injections are made in small amounts to help prevent lumpy areas from forming in the breast, also known as “fat necrosis.” Fat grafting is done to help increase the size of the reconstructed breast and to make the shape of the breast appear more natural.

Fat Grafting

Fat grafting is a process that is often performed as a part of a post-mastectomy breast reconstruction.

Anne Peled, MD

Plastic Surgery

Dr. Peled is a practicing breast cancer and plastic surgeon based in San Francisco. She is board-certified in plastic surgery and has fellowship training in breast surgical oncology, making her uniquely able to offer both breast oncologic and reconstructive surgical care. She is the co-director of the Breast Care Center of Excellence at Sutter Health California Pacific Medical Center. She has an extensive research experience focused on improving outcomes after breast cancer surgery and breast reconstruction and is currently involved in research looking at novel approaches to optimize patient satisfaction and quality-of-life after breast surgery.

Sensation Preserving Mastectomies
Sensation Preserving Mastectomies
Sensation Preserving Mastectomies
Sensation Preserving Mastectomies

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A sensation-preserving mastectomy involves saving the nerves when “oncologically safe.” This means the nerves need to either run in the fatty tissue layer beneath the skin where they can avoid being cut or reconstructed after being cut during the mastectomy, which is the case if the nerves run through the breast tissue instead of staying in the fatty tissue layer.

Each person’s situation is unique, so to determine if you are a candidate for a sensation-reserving/nipple sparing mastectomy, it is essential to undergo an evaluation. The results of your evaluation will help you learn if the procedure is right for you and what the best choices are for your reconstruction, so you and your surgeon can come up with a final surgical plan.

The reason this happens is because the nerves to the breast skin and nipple travel through the breast tissue, and these nerves get cut during a traditional mastectomy.

Once these nerves are cut, breast and nipple numbness occur and, in some cases, women may even suffer painful sensations at the ends of the cut nerve. Because of the variable nerve anatomy in the breasts, there are some women who may get lucky and have sensation gradually return over time without active preservation of nerves during surgery, but most women will not.

This type of mastectomy, which was developed by Drs. Anne and Ziv Peled, utilizes an innovative technique that preserves and grafts the nerves that are typically injured during a mastectomy surgery. By undergoing a sensation-preserving mastectomy, a woman will have a significantly greater opportunity to feel like herself again. And perhaps even more importantly, she won’t have to endure a lifetime reminder of her breast cancer surgery because of constant chest numbness.

Many women even report that they often forget they had a mastectomy and reconstruction surgery because their reconstructed breasts feel so much like their breasts prior to surgery.

There are four common incision types for nipple-sparing/sensation-preserving mastectomies, all of which allow scars to heal well and fade over time: inframammary fold (underneath the breast), peri-areolar (around part of the areola), lateral (from the side of the areola out towards the side of the breast), and inferior vertical (from the bottom of the areola down towards the bottom of the breast).

For most patients, a sensation-preserving double mastectomy and implant reconstruction takes about three to four hours of surgery, with an overnight stay in the hospital or surgery center. As for post-surgical recovery, most women return to their daily lives and activities within two weeks, with complete recovery in most cases in four to six weeks.

However, sensation-preserving mastectomies are fast-gaining in popularity and as a result more and more surgeons are utilizing the technique. If you are diagnosed with breast cancer or are interested in having a prophylactic mastectomy performed because it runs in your family, then you should ask your surgeon if they have experience with nerve sparing mastectomy and reconstruction.

Today, most mastectomies performed are either skin-sparing, where all the breast skin except for the nipple and areola is saved, or nipple-sparing, where all of the breast skin including the nipple and areola skin is saved.

When a modern mastectomy is performed with breast reconstruction, it results in the reconstructed breast looking more natural and more like the breast before mastectomy. And when sensation-preserving techniques are employed during the reconstruction, the reconstructed breast not only looks like the breast before the mastectomy, it also feels like it.

Between 80% and 90% of women choose implant reconstruction because flap reconstruction is a much more invasive type of surgery and as a result, it requires a much longer procedure time and hospitalization, as well as extensive recovery after surgery.

The main benefit of implant-based reconstruction is that no large additional scars outside of the breast are needed and the post-operative recovery is often easier, with a typical two- to four-week recovery period. Implant-based reconstruction for mastectomy can be done in either one stage (direct-to-implant), where a permanent implant is placed at the time of mastectomy, or in two stages, where a temporary implant called an expander is placed at the first stage and switched to a permanent implant at the second stage.

The decision on which approach to use is based on pre-mastectomy breast size and shape, patient goals, and intra-operative assessment following mastectomy. Implant-based reconstruction may also include fat grafting at the second stage of reconstruction to help give the reconstructed breast as natural an appearance as possible.

Many plastic surgeons are now realizing that selected patients may be able to have direct-to-implant reconstruction surgeries, in which an implant is placed at the time of mastectomy. This is also called a “One and Done” mastectomy. The benefits of this approach are that women can avoid the need for a second surgery and get to their final reconstructive outcome more quickly.

Both silicone and saline implants are available in round and teardrop shapes, and they both come in different levels of projection across different volumes. Of the two, silicone implants are softer to the touch and are considered by many women to feel more like natural breasts, but saline implants are safer in cases of rupture because the saline can be safely absorbed by the body. Ultimately, it is up to you and your doctor to choose which type of implant will work best for your unique situation and whether the implant will be inserted over or under the muscle.

It is most done during the second stage of reconstruction, and it involves liposuction of fat from the abdomen or thighs. Once the fat is collected, it is specially processed in the operating room to get it ready for transfer and then carefully injected throughout the mastectomy skin flap and sometimes the chest wall muscles. The injections are made in small amounts to help prevent lumpy areas from forming in the breast, also known as “fat necrosis.” Fat grafting is done to help increase the size of the reconstructed breast and to make the shape of the breast appear more natural.