Breast conservation therapy has been the cornerstone of the surgical treatment of breast cancer for the last 20 years; however, recently, the use of mastectomy has been increasing. Mastectomy is one of the most frequently performed breast operations, and with novel surgical techniques, preservation of the skin envelope and/or the nipple-areolar complex is commonly performed. The goal of this paper is to review the literature on skin-sparing mastectomy and nipple-sparing mastectomy and to evaluate the oncologic safety of these techniques. In addition, this paper will discuss the oncologic importance of margin status and type of mastectomy as it pertains to risk of local recurrence and relative need for adjuvant therapy. 1. Introduction Since the advent of Halsted’s radical mastectomy in the 1800’s, the surgical treatment of breast cancer has become increasingly refined. Today, the radical mastectomy is rarely performed, however, with breast cancer affecting nearly one in eight women [1], it remains an important part of breast cancer treatment, especially for more advanced or locally aggressive tumors. Since the increasing trend towards breast conservation therapy (BCT), the surgical literature has focused on the predictors of locoregional recurrence (LR) after BCT. However, there has been a recent swing on the pendulum back towards a higher rate of mastectomy [2], utilizing new surgical techniques where the skin and/or nipple-areolar complex (NAC) can be preserved. These techniques are being used to improve postoperative cosmesis, and it is important to understand how these procedures differ from the basic modified-radical mastectomy (MRM), and how important particular demographic, technical, and tumor-specific factors are at predicting LR and oncologic safety with these various techniques. 2. The Skin-Sparing Mastectomy The modified radical mastectomy (MRM), or traditional non-skin-sparing mastectomy (NSSM), most commonly performed today, was described by Madden in 1965. This procedure involves removal of all breast tissue, while preserving both pectoralis muscles, and it is commonly accompanied by dissection of level I and II axillary lymph nodes if indicated [3]. A locoregional recurrence (LR) rate of roughly 10% at 5–8 years is deemed acceptable by many authors [4–7], with most LR occurring within the first five postoperative years [5]. The skin-sparing mastectomy (SSM) was first described in 1991 by Toth and Lappert [33] as an effort to maximize skin preservation to improve cosmetic outcome and facilitate reconstruction. It typically entails removal
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