Introduction to conservative mastectomies

The definition of conservative mastectomies was first introduced in the medical literature by Dr. Nava et al., of the Istituto Nazionale dei Tumori Milano, Italy (1).

Nowadays, the aesthetic result for primary treatment of breast cancer patients is as important as oncological safety and must be the actual goal of the breast surgeon. In this context, new surgical procedures emerged as “conservative mastectomies”, expanding the concept of a better outcome for breast conservation procedures.

In the last 50 years, breast surgery evolved from maximum tolerable treatment with aggressive and mutilating interventions, like radical mastectomy, to minimum effective treatment, and from an anatomical concept of cancer spread to a biological concept.

Conservative mastectomies incorporate the advantage of tumor and total gland excision, as in a traditional total mastectomy, with improvement in the esthetic result through conservation of the skin envelope and the nipple areolar complex (NAC). The use of anatomical expanders and high cohesive silicone implants ensures high quality immediate reconstruction in these patients, but autologous tissue can also be used to fill the empty skin pocket after gland resection.

At first glance, conservative mastectomy (CM) may appear similar to subcutaneous mastectomy, which was first described by Freeman (2), and it’s still used for risk reduction.

However, there are two significant differences: the thickness of the skin flaps and the presence of retroareolar tissue.

As a curative procedure, CM incorporates the entire breast parenchyma, sparing only the skin, or in selected cases utilizing NAC preservation (3).

NAC ischemia and necrosis are some of the expected complications; however, solutions for these are technically simple. The issues relevant to the technique are oncological safety and long-term follow-up.

Three different techniques for CM that have been oncologically validated are:

• —skin-sparing mastectomy (SSM) (4);
• —nipple-sparing mastectomy (NSM) (5);
• —skin-reducing mastectomy (SRM) (6).

CM by using any of these three techniques is indicated when mastectomy is unavoidable, or when the patient prefers a mastectomy instead of breast conservation surgery (BCS). CM is also indicated for small breasts, when more than 30% of the breast volume must be resected and the cosmetic result after radiotherapy (RT) will be poor.

Preserving skin, NAC, and the inframammary fold (IMF) enables improved immediate reconstruction with both implants and autologous tissue (Tables 1-6).

Table 1 Indications for SSM
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Table 2 Contraindications for SSM
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Table 3 Indications for NSM
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Table 4 Contraindications for NSM
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Table 5 Indications for SRM
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Table 6 Contraindications for SRM
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The difference in terminology between these approaches to breast cancer is important.

BCS with Previous RT has been accepted since the 1980s as a standard therapeutic modality for low-grade breast cancer.

This is a partial breast resection that includes lumpectomy (removal of the lump), quadrantectomy (removal of one quarter, or quadrant, of the breast), and segmental mastectomy (removal of the cancer, some of the breast tissue around the tumor, and the lining over the chest muscles beneath the tumor). A universally accepted basic oncological priority is to maximize disease control and obtain a satisfactory cosmetic outcome.

Different oncoplastic planning approaches and techniques can be used to improve the final cosmetic result in BCS (9,10), with rigorous selection of candidates. In addition to a complete history and physical examination, the most important guideline includes preoperative diagnostic imaging, including magnetic resonance imaging (MRI) (Tables 7,8).

Table 7 Indications for BCS
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Table 8 Contraindications for BCS
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Desirable cosmetic result in BCS and in CM is mandatory and a key factor in selecting an approach, when oncologic safety is guaranteed with either modality (11).

Different CM techniques appear to combine oncological safety with high quality cosmetic outcomes (12,13), and this procedures are an extending concept of breast preservation. Cooperation between breast and reconstructive surgical teams is still necessary, and both teams must be aware of the oncological and plastic surgery approaches and oncoplastic technique for each case (14). CM offers today an important psychological benefit and oncological safety for a large group of breast cancer patients.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

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