Mastectomy

Many women are candidates for incision via the inframmamary fold (the bra line). I had mine done this way and one can hardly tell that I had a mastectomy. This is often available for small and medium breasted women, less so for women with large breasts. Be sure to discuss this option with your doctor to see if you are a candidate. Many do not offer this option, so be sure that you determine if you are not a candidate or if your surgeon simply does not offer the procedure. The incision will vary with the type of mastectomy being performed, and whether or not there is reconstruction. For example, in nipple-sparing mastectomy (NSM), one incision is made (which can be placed in several different ways, extending laterally from the edge of the areola, or vertically down from the areola being two examples). The incision length with vary with breast size. NSM is done in conjunction with immediate breast reconstruction. With skin-sparing mastectomy (SSM), the nipple and areola are removed, and the majority of the breast skin is left to provide a bigger skin envelope for reconstruction. For mastectomy without reconstruction, the incision is necessarily larger, as the goal is to have the remaining skin flaps lie flat on the chest wall. That way a prosthesis can be worn more easily.

In patients prone to keloid, steroid can be injected into the wound at the time of closure (Kenalog10) to minimize an exuberant scar.

I opted for a bilateral. I only had cancer on the right side, but after finding that and getting my MRI, something popped on the left. We weren't sure what it was. I could have had it tested, but at that point I just knew I wanted to have both sides removed. So I chose to not get that side tested and proceed with a bilateral mastectomy.

After surgery, pathology showed it was not cancer, but I don't regret
making that decision. It was 100% correct for me.

That said, what is right for me, may not be right for you. And it's a hard decision to make. And I wish you best of luck making it. You have to do what you think is right for you, and only you. ((hugs)) I have only had the one breast removed. I discussed it a lot with my oncologist and did a lot of reading about recurrence. Plus I had 5 months to think about it during chemo. My oncologist said as long as being checked, going for mammograms and tests was not going to drive me crazy with worry, then I did not have to remove the other breast. What I read at the time is that most recurrence occurs in the same breast or in another organ. I knew that I would have radiation after the surgery so even the plastic surgeon I consulted beforehand said to come see him again 3-6 months after radiation was over. I think I decided to go with the simplest surgery possible hoping that recovery would be easier. I hear women say they choose the bilateral so that they will not have to go thru this again. My research did not find that reasoning to be valid. Breast cancer can recur and metastasize no matter what stage you have and what treatments you undergo.

The NCCN publishes guidelines for followup.
http://www.nccn.com/files/cancer-guidelines/breast/index.html#/86/
Physical exam is indicated every 4-6 months initially. Annual blood work and tumor markers are often drawn. There is a trend away from routine imaging in asymptomatic patients. A woman who has had bilateral mastectomies with negative nodes, assuming she is younger than age 75 and otherwise healthy, will probably have chemotherapy, depending on hormone receptors, etc, so she will be followed by her medical oncologist, as well as her breast surgeon. Initially women are seen every 3 months, and then later maybe every 4-6 months. I had a mastectomy in 2004 and because I am an imaging person I do CT scans on myself every year. But my oncologist does blood work more frequently than once a year, like 3 times, and they check tumor markers every time. Tumor markers are a good way to evaluate if a tumor is active or recurring. Decisions to perform CT, MRI or PET scanning are made on an individual basis, in my experience. There are so many variables. These decisions might also depend on the area that a person lives. Is there a very strong imaging department? Is it a tertiary care center with interns and residents, and is there a lot of research?

Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves. Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves.

It depends on the patient and if reconstruction is performed, and what type of reconstruction. If a mastectomy without reconstruction is performed, usually a 24-48 hour hospital stay is required, and a patient is discharged with drainage tubes in place. The drains are usually removed after about 7-10 days, but may stay in place longer depending on the amount of fluid that is being produced. Overall recovery in terms of return to work and other normal activities can take anywhere from 2-3 weeks up to 6-8 weeks.

If reconstruction is performed using tissue expanders or implants, the recovery is similar to that of a mastectomy without reconstruction but the initial pain is usually more as the tissue expanders or implants are placed underneath the pectoralis muscle. If reconstruction using muscle or fatty tissue is performed, the hospital stay is usually 3-5 days, and may include an intensive care unit stay; overall recovery is typically 6-8 weeks and sometimes longer. It depends on the patient and if reconstruction is performed, and what type of reconstruction. If a mastectomy without reconstruction is performed, usually a 24-48 hour hospital stay is required, and a patient is discharged with drainage tubes in place. The drains are usually removed after about 7-10 days, but may stay in place longer depending on the amount of fluid that is being produced. Overall recovery in terms of return to work and other normal activities can take anywhere from 2-3 weeks up to 6-8 weeks.

If reconstruction is performed using tissue expanders or implants, the recovery is similar to that of a mastectomy without reconstruction but the initial pain is usually more as the tissue expanders or implants are placed underneath the pectoralis muscle. If reconstruction using muscle or fatty tissue is performed, the hospital stay is usually 3-5 days, and may include an intensive care unit stay; overall recovery is typically 6-8 weeks and sometimes longer.

There's a saying about New York that applies to the breast-cancer community too: There are 8 million stories in the naked city.

Every woman with breast cancer has a specific set of factors she must consider in making decisions about her treatment. For some women, the choice is clear. For others, the decision-making process is the most stressful part of the breast-cancer experience.

My decision to undergo a bilateral mastectomy after having a lumpectomy and re-excision on my right breast was based on a unique set of circumstances: There was disagreement between my first- and second-opinion doctors about whether the margins around the re-excision were clear. My tumor was an unusually aggressive kind of lobular cancer, and women with lobular cancer are somewhat more likely to get a tumor in the other breast. My tumor hadn't shown up on the mammogram I'd had a couple of months before I was suddenly able to see and feel it, so I was concerned that a new tumor wouldn't be found by mammography either. Both breasts were dense and had areas of micro-calcifications—risk factors for breast cancer—so I was going to require frequent monitoring of various kinds.

All those concerns, plus the fact that I'm a worrier by nature, led me to choose the most aggressive surgery.

I actually didn't have much trouble deciding to have both breasts removed. But a friend suggested that I make a list of pros and cons so that if I ever felt regrets, I could look at the list and remember why I chose that course. I haven't felt regrets, as it turns out, but making the list was reassuring because I realized how certain I was about my decision.

Another woman in my situation might make a completely different decision. She might choose to keep one or both breasts. And I can understand that. After all, even my well-trained, experienced and talented doctors disagreed in their advice. But I feel confident that my decision was right for me. There's a saying about New York that applies to the breast-cancer community too: There are 8 million stories in the naked city.

Every woman with breast cancer has a specific set of factors she must consider in making decisions about her treatment. For some women, the choice is clear. For others, the decision-making process is the most stressful part of the breast-cancer experience.

My decision to undergo a bilateral mastectomy after having a lumpectomy and re-excision on my right breast was based on a unique set of circumstances: There was disagreement between my first- and second-opinion doctors about whether the margins around the re-excision were clear. My tumor was an unusually aggressive kind of lobular cancer, and women with lobular cancer are somewhat more likely to get a tumor in the other breast. My tumor hadn't shown up on the mammogram I'd had a couple of months before I was suddenly able to see and feel it, so I was concerned that a new tumor wouldn't be found by mammography either. Both breasts were dense and had areas of micro-calcifications—risk factors for breast cancer—so I was going to require frequent monitoring of various kinds.

All those concerns, plus the fact that I'm a worrier by nature, led me to choose the most aggressive surgery.

I actually didn't have much trouble deciding to have both breasts removed. But a friend suggested that I make a list of pros and cons so that if I ever felt regrets, I could look at the list and remember why I chose that course. I haven't felt regrets, as it turns out, but making the list was reassuring because I realized how certain I was about my decision.

Another woman in my situation might make a completely different decision. She might choose to keep one or both breasts. And I can understand that. After all, even my well-trained, experienced and talented doctors disagreed in their advice. But I feel confident that my decision was right for me.

For me this was not a difficult decision. When I learned that there was no survival benefit for mastectomy in my case, I decided to keep my breast and have radiation therapy. The prospects of a smaller surgical procedure as well as my appearance and sensation all seemed positive.

However, if I had carried the BRCA gene or if any other medical situation had made mastectomy an appropriate choice, I would not have hesitated to choose it. For me this was not a difficult decision. When I learned that there was no survival benefit for mastectomy in my case, I decided to keep my breast and have radiation therapy. The prospects of a smaller surgical procedure as well as my appearance and sensation all seemed positive.

However, if I had carried the BRCA gene or if any other medical situation had made mastectomy an appropriate choice, I would not have hesitated to choose it.

Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine. Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine.

I honestly never considered a lumpectomy. I wanted to be as aggressive as possible and leave no breast tissue behind. I was young and had a fairly large tumor and lymph node involvement so I felt like that was the best choice for me. I honestly never considered a lumpectomy. I wanted to be as aggressive as possible and leave no breast tissue behind. I was young and had a fairly large tumor and lymph node involvement so I felt like that was the best choice for me.

Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate. Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate.

I would say that this is very normal to have these difficulties, but would also say that with time most of my patients are very happy with their reconstructions, and these emotional difficulties usually go away with time. I also have a number of patients who have finished the reconstruction process and have volunteered to speak with new patients, and this can often be very helpful for new patients. Additionally, having a very understanding spouse or significant other, as well as family and/or friends, is usually very helpful. I would say that this is very normal to have these difficulties, but would also say that with time most of my patients are very happy with their reconstructions, and these emotional difficulties usually go away with time. I also have a number of patients who have finished the reconstruction process and have volunteered to speak with new patients, and this can often be very helpful for new patients. Additionally, having a very understanding spouse or significant other, as well as family and/or friends, is usually very helpful.

Just diagnosed for the 3rd time & had a double mastectomy and reconstruction during one surgery 3 weeks ago. Had the BEST surgeons in Santa Barbara and am forever grateful to them. Surprisingly the skin sparing went very well especially on my 20 yr. old radiated breast. They both said that they would not be able to spare my nipples so I had already made an appt. for tattoos and was considering nipple reconstruction. But, my genius surgeons in the middle of surgery decided to spare one nipple and part of the areola of the current breast cancer breast. I was so shocked and happy when my family shared the news with me after I came out of recovery. I gasped when they told me. So, even though I look in the mirror and see many stitches and atypical breasts at this point in time in the game looking back at me, seeing my nipple and part of the areola makes everything (including my psyche) more at ease. We are all dealt different cards on this journey and this aspect of my recovery has definitely lifted my spirits. Others not going through this journey may say it doesn't matter, but it does and I am truly grateful. I would have dealt with whatever was handed my way, but again, I am very happy with my outcome and can't wait to see how 'they' turn out after my final implant surgery in April! I had a great experience with the skin sparring surgery although we weren't able to save the nipple on one of my breast. I was able to have reconstruction done at the same time of mastectomy because my plastic surgeon did a skin sparring/nipple sparring double mastectomy and reconstruction all at once. I must say the results on my self-esteem were tremendous. I was already without air and felt crappy from chemo, being able to spare myself the trauma to be without breasts for many months, even a year was something wonderful to me.

I am quite happy with the results. Both breasts being perfectly similar (just had a nipple graff a few months ago). I think this is a wonderful medical alternative when you are sure you want to have reconstruction done. I think the younger the patient the more pertinent this may sound.

Mary

The sooner you can resume normal activities the better off you are. I don't mean push it, and I don't mean start doing jumping jacks. Start walking and add distance incrementally. And do this every day. One block, two, three, until you're comfortably walking a mile or so.

Equally important is the rehabilitation of your arm. If you haven't had physical therapy many excellent resources are mentioned above. You can run through arm exercises in fifteen minutes or so. I still do so to this day. After full lymph dissection and radiation the natural tendency of the arm and skin is to retract and tighten.

One of the best things I'e found is yoga. Many cancer treatment centers (in Houston through MD Anderson and Memorial Hermann) now offer yoga for cancer survivors. It's excellent and a gentle way to reduce stress.
I would assume that if you are back to work you are at least 6 to 8 weeks out of surgery. Most doctors will recommend you don't start an exercise program until you are 6 to 8 weeks out of surgery, so make sure you have your doctor's permission to exercise before starting a program. That being said, I always start with flexibility and range of motion. After surgical procedures related to breast cancer, we have a tendency to sort of hunch over in a forward position which causes tightening in the chest muscles and weakness in the upper back muscles. If you are going back to work in an office, this would probably mean you are sitting at a desk and working on a computer, which puts you automatically in the above-mentioned position. So, what are some exercises you can do at work to regain range of motion and flexibility?

I would start by sitting up straight in your chair, and doing some shoulder rolls. Shoulder rolls are great because they "set" your posture. So sit up straight in your chair and squeeze your shoulders up towards your ears, then drop them down while squeezing them back towards each other, then drop them down as if you are putting your shoulder blades in your back pocket. This is an exaggerated version of a shoulder roll, but it gets your shoulders moving and pulls them down and back where they belong. Try a few of these by doing the exaggerated version first, then simply roll them up, back and down.

Let me know if this helps!!

For a video of flexibility exercises you can do at home or at work, go to http://www.movingonfromcancer.com

Massage after mastectomy is generally considered to be beneficial. There was some concern a few years ago that massage may spread breast cancer cells. This notion has been overturned.

It has been shown that massage reduces anxiety, pain and requirements for pain medication. A study form the University of Miami showed that massage also increased levels of a brain chemical called dopamine, which helps produce a feeling of well-being. In addition there was an increase in protective white blood cells that help boost the immune system (called natural killer cells) from the first to the last day of the study. Not sure what you are referring to when you say "massage". Do you mean traditional massage or manual lymph drainage which is sometimes referred to as "massage" although it is not part of the traditional massage protocol?

Are you asking about having a massage for its generalized beneficial effects, or are you asking about massage as a component of post-mastectomy rehabilitation treating swelling, neuropathy, scar tissue and fibrosis?

This is the easiest question of all for me.
I was my mom's caretaker for 2 years. I literally went through her cancer diagnosis & treatment with her as well as taking her last breath with her.
When my next family member was diagnosed & we found out that we carried the BRCA gene mutation, in my mind it wasn't an if for me, it was a when.
I knew that I had to do everything that I could to not go down this road.(No woman in my family has lived past the age of 60.)
I knew that for me giving up my breasts & ovaries was my only choice with the odds stacked so high against me. In MY opinion taking prophylactic measures was far easier than the choices I would have to make if I developed one cancer cell. This is the easiest question of all for me.
I was my mom's caretaker for 2 years. I literally went through her cancer diagnosis & treatment with her as well as taking her last breath with her.
When my next family member was diagnosed & we found out that we carried the BRCA gene mutation, in my mind it wasn't an if for me, it was a when.
I knew that I had to do everything that I could to not go down this road.(No woman in my family has lived past the age of 60.)
I knew that for me giving up my breasts & ovaries was my only choice with the odds stacked so high against me. In MY opinion taking prophylactic measures was far easier than the choices I would have to make if I developed one cancer cell.

It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%. It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%.

In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks. In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks.

By far the best result and state of the art today involves Nipple Sparing Mastectomy(NSM) and immediate reconstruction with DIEP or other Perforator flaps. For an optimal outcome, it is crucial to have a breast surgeon well trained in NSM and the right plastic surgeon. Ideally a one stage mastectomy and reconstruction can be done. Typically the breast would have a faint scar on the under surface of the breast. The DIEP donor site should be the same as a cosmetic tummy tuck. If the abdomen is not a good option, skin and fat can be obtained from the posterior thigh leaving a scar concealed in the fold beneath the buttock. This is my most recent innovation and is called the PAP flap. By far the best result and state of the art today involves Nipple Sparing Mastectomy(NSM) and immediate reconstruction with DIEP or other Perforator flaps. For an optimal outcome, it is crucial to have a breast surgeon well trained in NSM and the right plastic surgeon. Ideally a one stage mastectomy and reconstruction can be done. Typically the breast would have a faint scar on the under surface of the breast. The DIEP donor site should be the same as a cosmetic tummy tuck. If the abdomen is not a good option, skin and fat can be obtained from the posterior thigh leaving a scar concealed in the fold beneath the buttock. This is my most recent innovation and is called the PAP flap.