For Women Who Face a Mastectomy, a Gentler Option

When Donna Watson, 51, was diagnosed with ductal carcinoma in situ (DCIS) in October 2009, the finding was as good as such news can get. It meant that the cancer was still confined to the breast ducts and had not yet spread to the surrounding tissue. But when word came back that an initial operation hadn’t removed all of the cancerous tissue, Watson struggled with what to do next.

“If I had a lumpectomy or a single mastectomy, I would still have to deal with five years of tamoxifen, more scarring, the possibility of developing cancer in my other breast, and a continuing fear of recurrence,” she says. “I just couldn’t face the psychological burden of all that testing and the drugs.”

So Watson started investigating the possibility of having a bilateral mastectomy. Nolan Karp, MD, associate professor of plastic surgery, director of the breast plastic surgery service at NYU Langone Medical Center, told her that she would be an excellent candidate for a groundbreaking surgical procedure: a nipple-sparing mastectomy. In a traditional mastectomy, all of the breast tissue is removed, and the breast is reconstructed using soft tissue from elsewhere, such as the abdomen and hips. More recently, breast surgeons have been performing skin-sparing mastectomies, in which they remove the cancerous tissue through a small incision, usually around the nipple’s areola. Most of the breast skin is left intact, creating a natural pocket that can be filled either with an implant or with the patient’s own tissue.

But this procedure still leaves the patient without a nipple. Although plastic surgeons can make realistic-looking nipples with tattooing or by folding skin on the new breast, it isn’t the same—and women know it. Over the past year, Dr. Karp and breast surgeon Richard Shapiro, MD, associate professor of surgery, have partnered to perform about 25 total skin and nipple-areola-sparing mastectomies. “About three-quarters of these patients are having totally prophylactic mastectomies—for example, if they have a greatly increased risk of developing breast cancer due to a significant family history of breast cancer, or if they carry a deleterious genetic mutation, such as BRCA 1 or 2,” explains Dr. Shapiro. “Other patients are women like Donna Watson who have cancers that are technically candidates for lumpectomies, but who opted for mastectomies.” The two procedures—the mastectomy and the reconstruction—are done on the same day.

Not everyone is a candidate for a nipple-areola-sparing mastectomy. Patients with larger tumors or with smaller tumors too close to the nipple are cautioned against it, as well as patients with extensive DCIS. The concern, of course, is leaving behind tissue that may contain cancer cells. “We don’t have long-term studies comparing this surgery to other forms of mastectomy,” notes Dr. Shapiro. “But the recurrence rates for women undergoing skin sparing mastectomy (but not saving the nipple and/or areola) are comparable to those treated by more conventional, less cosmetically acceptable, total or modified radical mastectomies. Since we’re already routinely saving substantial portions of the skin, leaving the nipple and a potentially very small amount of tissue beneath it may not add an appreciable risk.”

“Taking away the nipple is a big part of the emotional impact of a mastectomy,” explains Dr. Karp. "It’s probably everyone’s fear—how you will look,” says Watson. “But when I see myself naked, I don’t see any scars. It’s just incredible.”