about the procedure
1 - Surgical aims
- Excision of all breast tissue
- Reduction and repositioning of the areola
- Aesthetic scar placement
The major landmark on the male chest is the pectoral bulk and the lower edge this muscle produces- the subpectoral line. In the female chest, this muscle is still present, but less bulky and is obscured by the overlying breast. The landmark we notice is the lower curve of the breast mound- the infra-mammary fold.
Scars are thus placed around the areola and along the subpectoral line.
2 - technique
Although a mastectomy is the base procedure, there are two main techniques used to achieve it.
The choice depends on the size of the breast and the amount of excess skin that needs to be removed.
An incision is made within the areola to reduce its diameter and a second concentric incision is made around this at a distance of not much more than 2cm. The top layer of skin is removed from the tissue between these incisions. The superior half of the outer incision is made all the way through to the underlying breast tissue and is used to perform the mastectomy. After this is done, the outer incision is reduced with a purse string suture and sutured to the areola.
This is really only suitable for very small breasts (A cup or those approx 100g), as it does not allow for the removal of much skin.
The more skin removed, the more gathering is needed to close the incision and this can compromise the blood supply to the areola and nipple.
This involves a much larger incision approximating the width of the breast, with an elliptical excision of skin and all of the underlying breast tissue.
The scar is set at the lower border of the the pectoral muscle, following its curve upwards and outwards towards the armpit so that it stays in the subpectoral shadow.
This avoids dog ears on the lateral chest wall when the scar is kept as a horizontal line.
This is used in patients with larger breasts, where excess skin needs to be removed.
3 - the nipple & areola
The nipple is maintained via a skin connection in the keyhole technique, but when using the double-incision method, it can be managed in 3 main ways.
This is my preferred technique.
In this a bridge of tissue connecting the areola to the lower skin flap is maintained. This is called the pedicle. It is kept thick enough to carry a blood supply to the nipple and areola.
During the removal of breast tissue, the blood supply to the nipple complex is significantly decreased.
In large breasts it is not always possible to use this technique because the pedicle length increases.
A long pedicle:
– has more tissue to supply with blood which can increase the risk of nipple complex necrosis as it is the last part to recieve blood.
– is at greater risk of twisting or folding on itself and obstructing blood flow to the nipple complex.
– may leave a noticeable lump on the chest wall due to its bulk.
I will generally try to maintain a pedicle and check the nipple complex viability and bulk before inset. If the blood supply appears inadequate, I will convert it to a graft. I do what I think will be safest.
The second method is to completely remove the nipple, reduce its diameter and thickness and then reapply it as a graft once the mastectomy is completed.
A skin graft is a common technique used in plastic surgery and involves a new blood supply growing into the graft.
As the nipple is thicker that most grafts, it is usual to have slower healing with this method.
The third method is to excise the nipples completely and discard them.
This is less common and only done at specific patient request.
It is possible to get nipple tattood, but the dyes used do not tend to last as long as regular tattoos.
It is possible to perform nipple reconstruction surgery, which involves the elevation of flaps of skin and sewing them together to make a nubbin for the nipple. A skin graft or tattoo can then be used to make an areola.
4 - hospital
The surgery is performed in a fully accredited hospital under general anaesthesia and takes approximately 3-4 hours to complete.
Hospital stay is usually an overnight stay, with discharge around lunchtime the next day. Drains and intravenous lines are removed prior to discharge and you will be given medications or prescriptions to take home. A binder is recommended for the first 2 weeks after surgery.
At least 1-2 weeks should be taken off of work and you should avoid upper body exercise for at least 4 weeks.
5 - estimated fees
Surgical Fee $7000.00
Medicare offers approximately $1,100.00 in rebate for this, and private health another $400-500. Medicare and insurers will pay 100 % rebate for the first procedure, but then only 50% for the next (and 25% for any after) They assume that the more you do the easier and cheaper it is! But this is not the case and it often takes a little longer to match the second side to the first.
Anaesthetic Fee $1800.00 - 2400.00
The anaesthetic fee is approximately $1800.00 - $2400.00. There is a medicare and fund rebate available on the anaesthetic fee.
Hospital Fee $0 - $4300.00
The hospital fee will depend on whether you have private health insurance or not. The Medicare item numbers associated with the procedure (31524 x 2). If you have the appropriate level of insurance you are covered for the hospital fees bar any excess. If you do not have insurance, the hospital fees are approximately $4300.00.
Any breast tissue removed is sent to pathology for analysis. This incurs a separate fee with some medicare rebate available.
If you have private health insurance, you should ring your fund and quote the item numbers above to obtain confirmation of your cover and expected rebates.
Please contact us if you have further questions.