Nationwide trends show that mastectomy surgeries for both the treatment and the prevention of breast cancer are on the rise.
According to Brigham and Women’s Hospital, more than 100,000 U.S. women undergo some form of mastectomy each year. Since 2000, breast reconstruction surgery (a common surgical procedure done to reconstruct the breast following a mastectomy surgery) has experienced a 39 percent increase year-to-year, according to the American Society of Plastic Surgeons.
An article published in June 2018 in Gland Surgery described how, despite advances in breast oncologic surgery in the 19th century, a long period of confusion over techniques and effectiveness persisted. One key component has been completely undervalued — sensation recovery after mastectomy.
A Brief History of Mastectomy
A mastectomy is a procedure in which all the breast tissue is removed from the chest to treat cancer or reduce a person's breast cancer risk.
- Mastectomy surgery in the United States began with William Halsted’s radical mastectomy in 1882. This aggressive procedure, which involved the complete removal of the breast, skin, chest muscles, and lymph nodes (and which often caused major complications and sometimes death) was performed on most breast cancer patients well into the 20th century.
- In 1972, John Madden modified Halsted’s radical mastectomy by emphasizing the preservation of both pectoral muscles through a more conservative approach. According to an article in Current Surgery, in the 1980s, breast conservation became even more popular through partial mastectomy, lymph node dissection, and radiation.
- Today, various forms of mastectomy and reconstruction surgery are practiced, including but not limited to partial mastectomy, oncoplastic surgery, mastectomy (simple + radical), mastectomy and implant placement, and mastectomy and flap reconstruction.
Experts believe breast surgery has come a long way since Halsted, but we are only now, in recent years, paying attention to quality of life.
Surgeons Anne and Ziv Peled Pioneered Sensation-Preserving Mastectomies With Implant-Based Reconstruction
In 2017, at age 37, Anne Peled, MD, a dual-trained breast and plastic surgeon based in San Francisco, was diagnosed with breast cancer.
“I love to tell the story about sensation preservation, because truly it came from my dinner table with me and my husband, Ziv,” Dr. Peled says. “When I was diagnosed, I was really scared about going through a mastectomy because I was worried about what it would be like to have a whole part of my body be numb.”
Anne eventually decided to have a lumpectomy surgery because she says the idea of complete chest numbness was too much to wrap her head around.
Following her surgery, Anne and her husband, Ziv Peled, MD, a plastic surgeon with a specialty in peripheral nerves, together began to question why they couldn’t reconstruct nerves in the breast the same way nerves are preserved in other parts of the body.
“The application of peripheral nerve surgery to breast surgery such as mastectomy is really an extension or an outgrowth rather of the question, ‘If we can reconstruct nerves in the arm or the leg that have been injured or removed for whatever reason, why couldn't we do that in the breast?’” Dr. Ziv Peled says. “The long and short of the answer to that question is that you can, and our data have proved that so far."
How Is a Sensation-Preserving Mastectomy Different From a Traditional Mastectomy?
“With traditional mastectomies, all the nerves would typically be cut and most people would lose all their breast sensation,” explains Anne Peled. “They would also lose nipple sensation if they had a nipple-sparing mastectomy.”
In addition to losing sensation, post-mastectomy pain syndrome is a possible outcome of traditional mastectomy surgeries. According to the American Cancer Society, post-mastectomy pain syndrome is nerve pain in the chest wall, armpit, or arm that doesn’t go away over time. According to Ziv Peled, this is not uncommon after typical mastectomies with breast surgeons who haven’t been trained to look for nerves when operating.
“Whenever you cut a nerve, there's always a chance that you could injure that nerve,” he says.
What sets a sensation-preserving mastectomy apart from a traditional mastectomy is that nerves are intentionally either preserved or grafted using a technology called Resensation.
“When we use the term 'sensation-preserving mastectomy' in our practice, a surgery we've been performing for the last several years, we're really talking about trying to preserve any of the nerves that can be kept from an oncologically safe standpoint during the procedure,” says Anne Peled. “We reconstruct the ones that we can't.”
According to Anne Peled, the term is new; it has taken hold in the last couple of years but is still not something that's being done in most practices across the country and the world.
“As cancer surgeons, we all want to do the best thing oncologically, and I think there's a lot [highee] standard of care, from an oncologic standpoint,” she says. “I think where things start getting lost and things start getting missed, is people not thinking about quality of life and not thinking about patient goals.”
The lack of transparency about the likelihood of chest numbness following a traditional mastectomy is something Anne Peled wishes were discussed more so that patients could make a fully informed decision before surgery.
She also encourages patients to advocate for themselves by asking questions about what to expect after surgery and what recovery will be like. She also recommends pointing out to your surgeon that sensation does matter to you.
“We have this long history in breast cancer surgery of evolving to find ways that are still oncologically safe, but we don’t do a better job with quality of life. And to me, sensation preservation is just that next step to that final frontier in mastectomy surgery,” she says.
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Who Is a Candidate for a Sensation-Preserving Mastectomy?
Anne and Ziv Peled's patients include those who have been diagnosed with breast cancer and those who are acting preventively to reduce breast cancer risk.
“Anyone who is a candidate for a mastectomy is really a candidate for sensation-preserving mastectomy,” says Anne Peled. “There are nuances around the type of reconstruction, but when we're doing a mastectomy, we should be able to not injure nerves and to reconstruct the nerves that are going through the breast that we need to connect.”
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Sensation-Preserving Mastectomy Results: When Sensation Comes Back and How It’s Measured
Together, Anne and Ziv Peled have performed nearly 300 sensation-preserving mastectomies and frequently treat patients who fly in from around the country to receive this surgery.
They have incorporated a sensory test and written survey to measure a patient’s levels of sensation before and after the mastectomy procedure. “We like to do the sensory test whenever possible before the operation because this gives us a baseline reading for what is ‘normal’ for you. So we know where you start and the goal is to get as close to that as possible afterward,” Ziv Peled says.
The neurosensory testing will sometimes be repeated at several points after surgery, but they have found that the most important times to do the test are around 6 months and then again 12 months after the surgery.
“We’re finding a good correlation between the neurosensory test results in which the numbers fall within the good to excellent range for sensation both at the breast skin and nipple. That correlates very well with patients reporting on their surveys that they have good to excellent sensation in those same areas of the breast,” he says.
The research the Peleds published in July 2019 in the journal Plastic and Reconstructive Surgery demonstrates that their technique combining oncologic, reconstructive, and peripheral nerve surgery leads to improved sensory outcomes. In their study, 16 women who underwent a nipple-sparing mastectomy with direct-to-implant reconstruction experienced a 90 percent rate of preserved sensation.
Anne takes to social media to help spread the word about sensation-preserving mastectomies. She says she often has other hospitals and surgery centers calling to ask her about the technique because of pressure from their patients.
Both Peleds are fueled to create resources that weren’t available to Anne at the time of her diagnosis.
“I know that the choice that I made to have a lumpectomy was the right one for me. But the reality is if I had had the option of sensation preservation, I really might have considered a mastectomy,” she says. “I am really excited to think that now people who are in the same situation as me get to have all the choices available to them."
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