Total / Simple Mastectomy
What the Examiner Expects
Complete removal of all breast tissue including the nipple-areolar complex. The examiner expects you to know the indications: multicentric/multifocal disease, positive margins after lumpectomy re-excision, inflammatory breast cancer (after neoadjuvant chemo), BRCA mutation carriers (prophylactic), patient preference, and contraindications to radiation. Skin-sparing mastectomy preserves the skin envelope for immediate reconstruction and is oncologically equivalent for non-inflammatory cancers. Nipple-sparing mastectomy additionally preserves the nipple-areolar complex and is appropriate for prophylactic mastectomy or cancers located > 2 cm from the nipple with a negative retroareolar margin.
Key Examiner Focus Points
- Removes all breast tissue, nipple-areolar complex, and skin envelope
- No axillary lymph node dissection (ALND) unless nodes are clinically positive
- Sentinel lymph node biopsy (SLNB) performed concurrently for staging
- Nipple-sparing mastectomy appropriate for prophylactic or early cancer with adequate nipple margin
- Skin-sparing mastectomy preserves skin envelope for immediate reconstruction
Common Curveballs
Retroareolar frozen section during nipple-sparing mastectomy is positive
Remove the nipple-areolar complex — convert to a skin-sparing mastectomy. A positive retroareolar margin means tumor involvement at the nipple and nipple preservation is oncologically unsafe.
Patient with inflammatory breast cancer requests immediate mastectomy
No. Inflammatory breast cancer requires neoadjuvant chemotherapy FIRST. Modified radical mastectomy is performed after completion of chemotherapy (typically 4–6 months). Surgery first is associated with poor outcomes — the skin and dermal lymphatics must be treated systemically before resection.
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