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Women with breast cancer and those who are at increased risk of developing breast cancer may consider mastectomy as an option for treatment or a step toward risk reduction. Historically, mastectomy in the absence of breast reconstruction was associated with a significant change in body image. For this reason, breast-conservation therapy emerged as an oncologically safe and emotionally less impacting option for the surgical treatment of breast cancer. Following the reporting of pivotal trials from Milan and the National Surgical Adjuvant Breast and Bowel Project (NSABP) in the 1970s and 1980s, breast-conservation rates rose dramatically. In recent years, however, mastectomy rates are increasing. This is thought to be at least in part due to improvements in cosmetic outcomes after mastectomy.

Initially the Halsted radical mastectomy, which resected en bloc the breast, regional lymph nodes, and underlying pectoralis muscles, left a severely disfigured chest wall and resulted in significant morbidity. Adoption of the modified radical mastectomy (MRM) technique allowed preservation of the pectoralis major and minor muscles, and internal mammary and supraclavicular nodal basins, resulting in significantly less disfigurement and reducing morbidity. The goal of mastectomy is to remove all breast tissue; data suggest that approximately 95% of breast tissue is resected in a traditional simple or modified radical mastectomy. The anatomical boundaries of the breast are the clavicle superiorly, the inframammary fold inferiorly, the sternum medially, and the mid-axillary line laterally. Sufficient skin overlying the chest wall is preserved at the time of a simple mastectomy in order to allow coverage of the chest wall and primary closure of the incision.

Since the skin is not part of the glandular breast tissue itself but rather an envelope around the breast tissue, the idea of preserving the skin envelope led to the development of skin-sparing mastectomy (SSM). Skin-sparing mastectomy was first described by Toth and Lappert in the literature in 1991.1 I describes the procedure of mastectomy, either simple or modified radical, with a minimum amount of skin excision. The surgical skin excision must (1) include the nipple-areolar complex (NAC), (2) include the biopsy site, and (3) allow for access to the axilla for possible dissection. Also incorporated into the SSM definition are preservation of both the inframammary fold and any uninvolved skin. Early SSM excised an ellipse of skin encompassing the NAC and some of the surrounding skin medially and laterally, but preserved more of the skin overlying the breast than conventional mastectomy. This incision afforded wide access to the boundaries of the breast, and resulted in removal of a similar amount of breast tissue and a similar long horizontal incision, but preserved more of the skin envelope for immediate reconstruction. As the technique evolved, smaller and smaller incisions provided appropriate access to the breast tissue and maximal skin preservation. Currently, most surgeons utilize a circumareolar incision that resects the NAC while preserving the entirety of the breast envelope.

With the advent of SSM, investigators appropriately ...

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