Anatomical mastectomy: where oncologic precision meets reconstructive surgery

For more than a century, the word mastectomy has carried a substantial oncologic, surgical, and emotional weight (1). Few procedures in medicine have undergone such a radical conceptual transformation, moving from an operation defined by maximal extirpation to one increasingly characterized by anatomical precision, aesthetic preservation, and individualized biology-driven decision making (2). The biological understanding of breast cancer began to dismantle the paradigm of surgical radicality (3).

In this broader landscape of surgical de-escalation, mastectomy itself did not disappear. Despite advances in conservation, mastectomy remained necessary for selected patients due to tumor extent, multicentricity, genetic predisposition, or patient preference. The question, therefore, became not whether mastectomy could be avoided in all cases, but whether mastectomy itself could evolve (4).

The term conservative mastectomy emerged to describe this new philosophy in modern oncologic breast surgery, emphasizing that even when mastectomy is unavoidable, it should conform to acceptable aesthetics and minimize disfigurement (5,6).

Over the past 15 years, conservative mastectomy has become widely validated and increasingly standardized. Nipple-sparing mastectomy, skin-reducing mastectomy, and immediate reconstruction are now routinely performed in many high-volume centres, with robust evidence supporting oncologic safety.

However, the continued use of the term conservative mastectomy may now be conceptually limiting. Modern mastectomy is performed with a level of precision that reflects advances in anatomical understanding and reconstructive integration in earlier decades (7). Surgeons increasingly respect fascial planes, preserve vascular networks, and optimize the three-dimensional architecture of the breast envelope. Reconstruction is no longer an afterthought but an integral component of oncologic surgery (8).

In this sense, the defining feature of today’s mastectomy is not merely what is preserved, but how the gland is removed. This concept more accurately reflects the current approach, which is increasingly based on precise glandular excision along natural anatomical, embryologic, and fascial planes.

Anatomical mastectomy may be defined as the complete excision of the mammary gland through dissection along the superficial fascial system, with preservation of the full subcutaneous layer of the mastectomy flap and maintenance of the subdermal vascular network, while respecting the nipple-areola complex when oncologically appropriate. Importantly, this preservation-oriented approach does not compromise oncologic safety, as anatomical mastectomy, by definition, entails complete glandular removal. Therefore, when correctly performed along established anatomical planes, preservation of the skin flap architecture and vascular integrity is not expected to compromise oncologic safety when complete glandular excision is achieved.

This term is not intended to replace established classifications, but to integrate them within a broader concept based on oncologic radicality, anatomical precision, flap preservation, and reconstructive planning.

A critical aspect is the deliberate preservation of the entire subcutaneous layer of the skin flap. Maintaining adequate flap thickness supports perfusion through the subdermal plexus, reduces ischemic complications, and improves reconstructive safety.

Furthermore, anatomical mastectomy optimizes implant coverage, improves breast contour, and facilitates modern approaches such as prepectoral reconstruction. The mastectomy flap is no longer a passive envelope but an active biological structure that determines reconstructive success.

Finally, ongoing technological refinement, including endoscopic or robotic techniques, and emerging applications of artificial intelligence, further enhance surgical precision and minimize the operative footprint (9).

In this context, anatomical mastectomy captures the essence of a procedure that is anatomically respectful, biologically justified, and technically advanced, offering a more accurate definition of what mastectomy truly represents today.

The evolution of mastectomy cannot be separated from advances in reconstruction. Contemporary breast reconstruction has undergone substantial refinement, including the wider adoption of prepectoral implant placement and the development of new reconstructive strategies and technologies. Although outcomes may vary according to patient selection and surgical technique, these advances have broadened reconstructive possibilities and reinforced the integration of oncologic and reconstructive principles within modern breast surgery (10-12). Consequently, mastectomy is increasingly considered not only in terms of cancer removal, but also in relation to the quality of reconstruction and patient-reported outcomes.

Anatomical mastectomy may represent the most accurate definition of modern mastectomy: not simply a less aggressive operation, but a biologically driven, anatomically guided, reconstructively integrated procedure. In an era where breast cancer surgery continues to move toward minimalism, the challenge is not only to reduce what we remove, but to redefine what mastectomy truly means.

Acknowledgments

None.

Footnote

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