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Mastectomy

A mastectomy is a surgical procedure involving the removal of one or both breasts, encompassing all breast tissue, and is principally performed to excise breast cancer or to prevent its development in individuals at elevated genetic risk. Common variants include the simple (total) mastectomy, which removes the breast tissue while preserving the overlying skin, nipple-sparing mastectomy, which retains the nipple-areola complex alongside skin for potential reconstruction, skin-sparing mastectomy, which excises breast tissue but conserves most overlying skin, and modified radical mastectomy, which additionally removes axillary lymph nodes to address potential metastasis. Historically, the procedure evolved from rudimentary excisions documented over 3,000 years ago to the radical mastectomy pioneered by William Halsted in 1882, which en bloc resected the breast, pectoral muscles, and axillary contents under the premise of local disease containment, though it yielded high morbidity and was later supplanted by less invasive techniques amid evidence favoring breast-conserving surgery for early-stage cancers. Primary indications encompass invasive breast carcinoma, ductal carcinoma in situ unresponsive to less extensive options, and prophylactic bilateral removal in carriers of BRCA1/BRCA2 mutations, where empirical data indicate a risk reduction exceeding 95%. Postoperative outcomes frequently involve reconstruction via implants or autologous tissue to mitigate aesthetic and psychological impacts, yet complications such as infection, seroma, flap necrosis, and chronic pain occur in up to 30% of cases, influenced by factors including obesity, smoking, and adjuvant radiation. Despite advances, mastectomy remains a definitive intervention for locally advanced disease or patient preference, balancing oncologic efficacy against functional and quality-of-life trade-offs grounded in tumor biology and host factors.

Indications

Breast Cancer Treatment

Mastectomy serves as a primary surgical intervention for , particularly in cases where breast-conserving surgery (BCS) is contraindicated due to factors such as tumor size exceeding 20-25% of volume, multifocal or multicentric disease, persistent positive margins after BCS attempts, , or patient preference for reduced local recurrence risk. (NCCN) guidelines recommend mastectomy for invasive when BCS would compromise oncologic safety or cosmetic outcomes, or in the context of neoadjuvant failure to achieve resectability via conservation. Historically, William Halsted introduced the in 1882, encompassing en bloc resection of the , , and , which dominated treatment for nearly a century under the assumption of contiguous lymphatic spread. This approach evolved with evidence from randomized trials demonstrating equivalent survival to less extensive procedures when combined with therapies. Randomized controlled trials, including the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial reported in 1995, established no significant difference in 10-year overall survival between mastectomy (75%) and BCS plus radiation (77%), with local-regional recurrence rates of 10% versus 5% respectively after adjusting for adjuvant chemotherapy. Meta-analyses of observational data, however, have reported potential survival advantages for BCS plus radiation in early-stage disease, with hazard ratios indicating up to 36% reduced overall mortality, potentially attributable to selection bias favoring healthier patients for conservation or unmeasured confounders rather than causality. Post-mastectomy locoregional recurrence rates typically range from 5-10% at 10 years in node-negative cases, rising to 20% or higher in those with four or more positive axillary nodes without radiation. Adjuvant radiation is indicated post-mastectomy for patients with tumor stage T3-T4, four or more positive nodes, or close/positive margins to reduce recurrence by 50-70%. In advanced stages, neoadjuvant may downstage tumors to enable BCS, but mastectomy remains standard for non-responders or triple-negative/basal-like subtypes with higher local failure risks. precedes axillary dissection to assess nodal involvement, guiding decisions on extent of and . Long-term breast cancer-specific exceeds 90% at 10 years for early-stage patients post-mastectomy with modern , though overall survival varies by molecular subtype, with HER2-positive and hormone receptor-positive cases benefiting most from targeted agents. Selection of mastectomy over BCS does not inherently confer survival benefits but offers definitive local control, influencing quality-of-life considerations such as options and psychological impact.

Prophylactic Use

Prophylactic mastectomy, also known as risk-reducing mastectomy, involves the surgical removal of one or both breasts in individuals at substantially elevated risk of developing , primarily to prevent its onset rather than treat existing disease. It is most commonly recommended for women carrying deleterious mutations in or genes, where lifetime breast cancer risk can reach 72% (95% CI, 65%-79%) for BRCA1 carriers by age 80. Other indications include strong family history of breast cancer conferring high risk, even without identified mutations, or rare syndromes like Li-Fraumeni. The procedure typically entails bilateral mastectomy to address risk in both breasts, though unilateral may be considered in select cases post-contralateral cancer diagnosis. Large prospective studies demonstrate that bilateral prophylactic mastectomy reduces incidence by 90-95% in /2 mutation carriers, with one of 483 high-risk women showing only 3% developed cancer post-procedure versus expected rates without intervention. A separate of 214 women with family history reported a 94% reduction in occurrence over 14 years of follow-up. While not eliminating risk entirely—due to residual chest wall tissue or occult disease at —mortality benefits accrue from averting advanced cancers, though direct data remain limited by ethical constraints on randomized trials. Guidelines from the (NCCN) and American Society of Breast Surgeons (ASBrS) endorse offering risk-reducing mastectomy to confirmed BRCA carriers after multidisciplinary counseling, emphasizing shared decision-making over routine surveillance or chemoprevention alone, which yield lesser risk reductions. Surgical risks include immediate complications such as (17%), (17%), and pain (35%), with overall rates lower in those forgoing (mean 0.93 complications per woman versus higher with implants or flaps). Long-term issues encompass , numbness, reduced arm mobility, and potential need for revision surgeries, though contralateral prophylactic mastectomy in unilateral cancer cases does not markedly elevate complication-related treatment delays. Psychological outcomes are predominantly favorable: most women report sustained satisfaction, decreased cancer-related anxiety, and preserved or improved emotional stability, , and up to 20 years post-surgery, with no evidence of widespread deterioration or decline in the majority. However, a minority experience heightened distress, particularly mutation carriers facing false alarms in residual screening, underscoring the need for preoperative .

Gender-Affirming Applications

Mastectomy in the context of , often termed chest masculinization or top surgery, involves the surgical removal of from transmasculine or individuals to achieve a flatter, more masculine chest contour, with the aim of alleviating psychological distress associated with secondary sex characteristics. The procedure typically includes excision of glandular , fat, and , followed by chest wall reshaping, with techniques varying by size and skin elasticity, such as double incision with free nipple for larger breasts or peri-areolar incisions for smaller volumes. This application differs from oncologic mastectomy in its elective nature and focus on cosmetic and psychological outcomes rather than cancer eradication. The prevalence of such procedures has risen sharply in recent years. , gender-affirming surgeries overall nearly tripled from 2016 to 2019, with and chest procedures comprising the largest category at over 56% of cases. Among adolescents, incidence rates increased 13-fold from 3.7 to 47.7 per 100,000 person-years between 2013 and 2020. A of 2,030 transmasculine patients reported 67% undergoing double incision techniques, reflecting adaptations to individual . Postoperative complications occur at variable rates depending on technique and patient factors. Overall complication rates range from 3.4% to 16.8%, with reoperations needed in about 6.2% of cases; common issues include hematoma (0% to 31.2%, averaging 4.9% in some series), seroma, infection, and nipple necrosis or loss, particularly higher with nipple-sparing methods. Patient satisfaction is frequently reported as high, with quality-of-life improvements in psychosocial functioning noted in multiple studies, though these rely on self-reported measures from gender clinic populations. Regret and rates following these mastectomies are cited as low, typically under 1% in systematic reviews pooling data from primarily short-term follow-ups (average 3.6 years), compared to 14.4% mean across elective surgeries. However, these figures face methodological critiques, including high loss to follow-up, in affirmative-care settings, and underreporting of due to social pressures or lack of long-term tracking, rendering true rates uncertain. Evidence quality remains limited by small sample sizes, absence of randomized controls, and potential conflicts in clinic-based research, with calls for more rigorous, longitudinal studies to assess causal impacts on and irreversible tissue loss.

Other Medical Indications

Mastectomy is occasionally performed for severe, refractory benign breast conditions unresponsive to conservative management. In cases of causing intractable pain, recurrent cyst formation, or diagnostic challenges due to multiple indeterminate masses, subcutaneous mastectomy may be considered to alleviate symptoms and reduce the risk of misdiagnosing occult , though this approach is rare and typically reserved for extreme scenarios after failure of medications like analgesics or hormonal therapies. For instance, policy guidelines indicate that such surgery may be appropriate when symptoms severely impair and imaging cannot reliably exclude cancer. Chronic or recurrent breast infections, such as large abscesses or periareolar failing repeated or antibiotics, represent another indication, particularly in non-lactating women where underlying inflammatory processes like granulomatous disease complicate resolution. In severe instances, including or bilateral extensive infections, partial or total mastectomy has been employed to excise necrotic tissue and prevent systemic , with case reports documenting rapid recovery post-procedure. This intervention is uncommon, as most abscesses resolve with percutaneous or antibiotics, but it is justified when conservative measures fail and tissue destruction threatens life. In males, mastectomy serves as a for involving significant glandular proliferation unresponsive to medical therapy, aiming to remove excess tissue and restore chest contour, often via subcutaneous techniques preserving skin. Trauma-induced injuries rarely necessitate mastectomy, with surgical more commonly limited to or repair unless extensive tissue loss occurs, though data on such cases remain sparse and outcomes emphasize over complete removal. Overall, these indications underscore mastectomy's role as a last-resort option for debilitating non-oncologic , with decisions guided by multidisciplinary assessment to weigh benefits against morbidity.

Types

Total Mastectomy

A total mastectomy, also known as a simple mastectomy, is a surgical procedure that removes the entire , including all glandular , the nipple-areola complex, and overlying skin, while sparing the underlying and minor muscles as well as unless a separate dissection is performed. This contrasts with more extensive procedures like , which also excise chest wall muscles and s en bloc. The operation is typically indicated for early-stage or multifocal where -conserving is not feasible, such as in cases of centrally located tumors or patient preference for avoiding . It is also employed prophylactically in women at high genetic risk, such as or mutation carriers, to reduce lifetime incidence by approximately 90-95%. The procedure begins with the patient under general anesthesia, followed by an elliptical incision encompassing the nipple-areola complex and centered over to facilitate removal of the skin envelope. The raises skin flaps superiorly and inferiorly, dissects the breast tissue off the , and removes the specimen intact, ensuring clear margins through pathological examination. Axillary may be integrated if is required, but full dissection is avoided to minimize risk, which occurs in less than 5% of simple mastectomy cases compared to 20-30% with full axillary clearance. Operating time averages 1-2 hours per , with hospital stays of 1-3 days depending on . Postoperatively, the chest wall is closed primarily, often with drains to manage formation, which affects up to 20% of s but resolves with conservative measures in most cases. , if pursued, typically involves implants or autologous tissue flaps placed subpectorally, though immediate reconstruction rates for total mastectomy are around 40-50% in the U.S., influenced by age and comorbidities. Local recurrence rates after total mastectomy alone are low, at 5-10% over 10 years for node-negative disease, comparable to plus radiation but without radiotherapy's side effects.

Radical and Modified Radical Mastectomy

The radical mastectomy, developed by American surgeon William Stewart Halsted in the late 1890s, represents an en bloc resection of the entire breast (including skin, nipple-areola complex, and glandular tissue), both pectoralis major and minor muscles, and the ipsilateral axillary lymph nodes to achieve wide local control in breast cancer based on the prevailing theory of contiguous lymphatic spread. This procedure dominated breast cancer surgery for nearly a century, with Halsted reporting a 5-year survival rate of approximately 30% in operable cases by 1907, though it carried significant morbidity including arm lymphedema, shoulder dysfunction, and chest wall deformity due to muscle sacrifice. By the 1970s, randomized trials demonstrated equivalent long-term survival compared to less extensive surgeries when combined with adjuvant therapies, leading to its obsolescence in favor of muscle-sparing alternatives; a 2002 New England Journal of Medicine analysis of a 25-year follow-up trial found relapse-free survival rates of 36% for radical mastectomy versus 33% for total mastectomy plus radiation in node-positive patients, underscoring no oncologic superiority. Today, radical mastectomy is reserved for rare instances of locally advanced disease with direct chest wall invasion, such as inflammatory breast cancer unresponsive to neoadjuvant therapy, comprising less than 1% of mastectomies in modern practice. The modified radical mastectomy (MRM), an evolution introduced by British surgeon Patey in 1948 and refined by Madden in 1972 to preserve both , removes the breast tissue, nipple-areola complex, overlying , and level I/II while sparing the pectoralis muscles to mitigate functional deficits without compromising cancer control. Unlike the Halsted radical, which excises muscles to ensure complete lymphatic clearance under the assumption of micrometastatic spread, MRM relies on selective node and preserves muscle integrity, reducing postoperative shoulder immobility and risk by up to 50% in comparative studies. The procedure typically involves a teardrop-shaped incision from the to the latissimus dorsi, elevation of flaps, of the breast off the chest wall, and axillary node sampling or clearance, often with sentinel lymph node biopsy to guide extent. MRM remains a standard for invasive cases where breast-conserving is contraindicated, such as multicentric disease, large tumors relative to breast size, or genetic predispositions like BRCA mutations necessitating prophylactic extension, with 5-year overall survival rates exceeding 80% in early-stage -positive cohorts when integrated with systemic therapies. Oncologic equivalence to approaches has been affirmed in multiple trials, including those showing no difference in locoregional recurrence (under 10% at 10 years) attributable to muscle preservation, as axillary s are the primary metastatic pathway rather than muscular lymphatics. Despite advances in nipple-sparing techniques, MRM's utility persists in resource-limited settings or for patients declining , though it is increasingly supplemented by targeted to de-escalate surgical extent.

Skin- and Nipple-Sparing Mastectomy

Skin- and nipple-sparing mastectomies represent refinements in mastectomy techniques designed to excise glandular while preserving the overlying envelope, thereby enabling immediate autologous or implant-based with enhanced aesthetic outcomes compared to non-sparing approaches. Skin-sparing mastectomy (SSM), first termed in by Toth and Lappert, involves removal of all parenchymal through limited incisions, retaining the native except for the nipple-areola complex () and any involved areas. Nipple-sparing mastectomy (NSM), an extension of SSM, additionally preserves the by undermining and mobilizing it after core confirmation of no involvement, ensuring complete glandular resection beneath. These methods originated from earlier subcutaneous mastectomies described in the for benign conditions but were adapted for oncologic use in the 1990s amid advances in , with NSM acceptance growing post-2000 following retrospective data accumulation. Indications for SSM and NSM are restricted to cases where tumor involvement of the skin or is absent, typically early-stage invasive (T1-T2) or without multicentricity, as confirmed by preoperative imaging and . Contraindications include tumors within 2 cm of the nipple, skin ulceration, , or Paget's disease, to minimize residual disease risk. Prophylactic use in carriers has also been validated, with no increased cancer incidence in preserved tissues over long-term follow-up. Intraoperatively, dissection proceeds in the plane between subcutaneous fat and gland, using electrocautery or harmonic scalpel for , with biopsy often integrated; the preserved skin flap thickness is maintained at 5-10 mm to avoid while ensuring oncologic clearance. Postoperative ischemia occurs in 5-10% of NSM cases, managed conservatively or with , but does not correlate with oncologic compromise when selection criteria are met. Oncologic safety is supported by multiple retrospective series and meta-analyses demonstrating equivalence to conventional mastectomy in local recurrence, disease-free survival, and overall survival. A meta-analysis of eight comparative studies reported a nonsignificant 3.4% overall survival advantage for NSM over skin- or modified radical mastectomy, with pooled local recurrence rates under 5% at 5 years. Five-year local recurrence-free survival reaches 95.8-100%, disease-free survival 82.5-94.1%, and overall survival 91.3-96.2% in NSM cohorts, comparable to non-sparing techniques when tumors lack retroareolar involvement. NAC-specific recurrence remains rare (1-4%), primarily linked to occult tumor biology rather than technique, underscoring the need for rigorous preoperative assessment over blanket contraindication. These outcomes hold across prophylactic and therapeutic settings, affirming SSM/NSM as viable for eligible patients prioritizing cosmesis without survival detriment, though long-term data beyond 10 years remain limited by procedure recency.

Surgical Procedure

Preoperative Preparation

Preoperative preparation for mastectomy involves a comprehensive to assess surgical candidacy, optimize health, and ensure informed . This includes a detailed review, focusing on comorbidities such as , , and pulmonary conditions that could impact tolerance or . evaluates overall fitness, breast tissue characteristics, and potential feasibility if planned. Laboratory tests typically encompass , coagulation profile, renal and hepatic function panels, and for patients over age 50 or with cardiac risk factors, aligning with guidelines for noncardiac surgery to minimize complications. For oncologic cases, preoperative imaging such as , , or MRI confirms disease extent and , though MRI's additive value remains debated due to potential over-detection without survival benefit. Patient optimization emphasizes modifiable risk factors to enhance outcomes. is critical, with recommendations to abstain for at least four weeks preoperatively to reduce , , and flap failure risks in scenarios. Control of and nutritional status through preoperative counseling improves healing, particularly in patients where correlates with higher complication rates. Multidisciplinary consultations, including clearance and, for prophylactic mastectomies, , address individualized needs; exercise programs may be advised to bolster postoperative recovery, though evidence is preliminary. In cases involving , timing surgery post-chemotherapy requires assessing residual effects like myelosuppression via recent bloodwork. Informed consent is obtained after thorough discussion of procedure specifics, alternatives like , risks including (2-5% incidence), , and phantom breast pain, and benefits tailored to indication—oncologic control, risk reduction, or alleviation. Documentation verifies patient comprehension, with emphasis on options if applicable, as regret rates vary by context but underscore the need for realistic expectations. Immediate pre-surgery instructions mandate nil per os status after midnight to prevent , preoperative showering without lotions or deodorants to reduce bacterial load, and discontinuation of anticoagulants per . These steps, grounded in surgical guidelines, aim to standardize preparation while accounting for patient-specific variables.

Intraoperative Techniques

The patient is positioned on the , with the ipsilateral arm extended or abducted to facilitate access to the breast and , and the table often tilted slightly to optimize exposure. General anesthesia is administered, and the surgical field is prepped and draped to include the breast, , and upper arm if is planned. Intraoperative techniques vary by mastectomy type but generally begin with incision placement. For total or simple mastectomy, an elliptical incision is made encompassing the , oriented diagonally to allow tension-free closure, extending from the lateral breast margin medially while incorporating any prior scars. In skin-sparing or nipple-sparing variants, incisions are minimized—such as periareolar, , or radial—to preserve the native skin envelope for , with the de-epithelialized or retained if oncologically safe. Flaps are then elevated using skin hooks, retractors, or electrocautery, maintaining a uniform thickness of 5-10 mm to prevent , extending superiorly to the or second rib, inferiorly to the , medially to the , and laterally to the latissimus dorsi edge. Dissection proceeds by elevating breast tissue off the , removing all glandular tissue including the , while sparing the muscle unless tumor invasion requires partial excision. Perforating vessels are coagulated or ligated with electrocautery or energy devices to achieve and minimize blood loss. Axillary , if indicated, involves sentinel lymph node using dye or radioisotope guidance or full through a separate incision, with intraoperative frozen section analysis for margin assessment in select cases. In skin-sparing procedures, dissection occurs at the superficial level to preserve integrity. Closure involves approximating skin edges without tension, often with quilting sutures to reduce risk, placement of closed-suction drains, and layered suturing using deep dermal, subcuticular, or staples. Lighted retractors or assistants enhance visualization, particularly in nipple-sparing techniques, to ensure complete tissue removal and oncologic margins.

Postoperative Care and Reconstruction

Following mastectomy, patients typically remain hospitalized for 1 to 3 days, depending on the procedure's extent and any concurrent reconstruction, with monitoring for bleeding, infection, and vital signs stability. Pain is managed with oral or intravenous analgesics, transitioning to non-opioid options as tolerated, while surgical drains are placed to prevent seroma formation and emptied regularly until output decreases below 20-30 mL per day, often over 1-2 weeks. Early mobilization, including supervised walking on the day of surgery, reduces thrombosis risk and promotes recovery, with arm elevation and gentle range-of-motion exercises initiated to mitigate stiffness and lymphedema. At home, wound care involves daily inspection for signs of such as redness, swelling, or , with incisions kept clean and dry; showers are permitted after 48 hours, but submersion in baths or pools is prohibited for 4-6 weeks until full healing. Patients are advised to avoid heavy lifting over 5-10 pounds, driving until off narcotics (typically 1-2 weeks), and strenuous activities for 4-6 weeks, while incorporating progressive for shoulder mobility, which addresses common postoperative stiffness resolving over 4-8 weeks. Nutrition emphasizes protein-rich diets to support healing, with follow-up appointments at 1-2 weeks for drain removal and review. Breast reconstruction, pursued by approximately 20-40% of mastectomy patients in high-resource settings, can occur immediately (during the same operation) or delayed (weeks to years later), with timing influenced by therapies like , which increases complication risks in immediate cases. Implant-based reconstruction, the most common type involving tissue expanders followed by permanent silicone or saline implants, offers shorter operative times but carries 10-20% rates of and , particularly post-. Autologous reconstruction, using flaps such as DIEP or latissimus dorsi, provides natural contour and sensation with lower long-term revision needs (success rates exceeding 95% for flap viability), though it entails longer (4-8 hours) and donor-site morbidity like abdominal weakness. Patient-reported outcomes indicate high satisfaction (80-90%) with for aesthetic and psychological benefits, though delayed procedures show fewer major complications (e.g., 5-10% vs. 15-25% for immediate) and better tolerance of . Non-surgical alternatives, such as external , are used by some to restore without operative risks, fitting into custom bras post-healing. Complications like or expander failure necessitate revisions in 10-15% of cases, with autologous methods demonstrating superior durability in irradiated fields. Overall extends 6-8 weeks with reconstruction, emphasizing multidisciplinary follow-up for adjustments and scar management.

Risks and Complications

Immediate Surgical Risks

Immediate surgical risks of mastectomy encompass perioperative complications such as , , , and , which typically manifest within days to weeks postoperatively and may necessitate reoperation or prolonged stays. These risks are generally low for simple or modified without , with major surgical complications (including , issues, and ) occurring in approximately 4.6-5.1% of cases across age groups. Factors like extent of axillary and patient comorbidities can elevate incidence, though age alone does not significantly increase surgical complication rates in older women. Hematoma, involving accumulation of blood in the surgical site, arises from inadequate or vascular disruption and occurs in 1-3% of mastectomy cases, often requiring evacuation to prevent further issues like or flap compromise. formation, a collection of lymphatic due to disrupted pathways, affects 15-18% of patients following modified radical mastectomy, with higher rates linked to axillary ; it commonly requires and can delay therapies. Surgical site , typically bacterial in origin from contamination, has an incidence of around 1-5%, manifesting as or and increasing reoperation risk. Intraoperative bleeding may occur from mammary vessels or , with transfusion rarely needed in uncomplicated cases but more frequent in radical procedures involving pectoralis removal. Adverse reactions to general , including respiratory depression or cardiovascular events, parallel those in other major surgeries, with rates under 1% in low-risk patients but heightened in those with or cardiopulmonary disease. Combined hematoma or requiring drainage affects about 9% of women undergoing mastectomy alone, underscoring the need for meticulous surgical technique and postoperative monitoring.

Long-Term Physical Complications

Lymphedema, characterized by persistent swelling in the , hand, or chest due to lymphatic disruption, affects approximately 20% of women long-term after mastectomy, with higher rates following axillary dissection (ALND). Risk factors include ALND, greater than 30, and mastectomy itself compared to breast-conserving , with incidence potentially reaching 19.9% after ALND versus 5.6% without. At 20 years post-treatment, up to 49% of survivors report sensations of lymphedema, with severe swelling (≥5 cm difference) in about 13%. This condition impairs mobility and increases infection risk, persisting indefinitely without intervention. Post-mastectomy (PMPS), a involving the chest wall, , or arm, occurs in 20-68% of patients, often persisting beyond 3-6 months. Characterized by burning, tingling, or shooting sensations, PMPS arises from intercostal or formation during , with prevalence up to 50% in some cohorts. Risk factors encompass preoperative , axillary dissection, and radiotherapy, transitioning from acute postoperative if inadequately managed. Approximately 10% experience severe impacting daily function. Impaired shoulder function, including reduced (ROM) and strength, affects 60-67% of survivors long-term, stemming from pectoral muscle disruption, scarring, and protective guarding. Early postoperative declines in ROM and strength persist to some degree, with 39% reporting hand and arm dysfunction at improving modestly over time but remaining elevated compared to baselines. Advanced cancer correlates with worse , limiting overhead activities and contributing to musculoskeletal imbalances. Additional long-term issues encompass numbness from transection and upper-body morbidity such as or restricted use, reported in 10-64% within 3 years. These stem from combined surgical trauma to neuromuscular, musculoskeletal, and lymphovascular structures, with axillary involvement exacerbating risks. may mitigate some functional deficits but does not eliminate them.

Psychological and Functional Impacts

Mastectomy frequently leads to distress among patients, with many reporting perceptions of their appearance as deformed, irregular, or ugly following the procedure. This distress correlates with elevated psychological symptoms, including and anxiety; one reported incidence at 21% and anxiety at 26% in total mastectomy patients. Compared to breast-conserving , total mastectomy is associated with higher risk, affecting approximately one in four women within one year post-. Breast reconstruction after mastectomy often mitigates these effects, improving well-being, , and satisfaction with breasts, while reducing anxiety and scores relative to mastectomy alone. However, without reconstruction, patients may experience persistent , , and coping challenges related to altered . Decision regret remains low in contexts, ranging from 5% to 21% for aspects of surgical choice, though younger patients report higher dissatisfaction rates. Functionally, mastectomy can impair upper extremity mobility due to , a common complication involving swelling from disrupted lymph flow, with risks up to 70% after modified radical procedures involving node removal. Self-reported prevalence is 13-65% one to three years post-surgery, correlating with reduced and overall . Despite these issues, long-term quality-of-life outcomes, including patient-reported satisfaction, are comparable between mastectomy with and breast-conserving alternatives, with improvements in treatment side effects over time. Prosthetic devices or aid in restoring contour and balance, supporting daily activities and reducing functional asymmetry.

Efficacy and Outcomes

Oncological Survival and Recurrence Data

In early-stage invasive (stages I-II), mastectomy combined with achieves 5-year breast cancer-specific survival (BCSS) rates of 94-97%, depending on tumor characteristics and nodal status. For instance, in a large , mastectomy alone yielded a 5-year BCSS of 94%, improving to 96% with added for higher-risk cases. Overall survival (OS) at 10 years following mastectomy ranges from 78-83% in population-based studies, influenced by comorbidities and adherence to endocrine or . Randomized controlled trials, such as those from the NSABP and EORTC, demonstrate equivalent long-term OS and BCSS between and breast-conserving (BCS) plus radiotherapy, with differences primarily in local control rather than systemic outcomes. However, recent observational data and meta-analyses of over 1 million patients suggest a modest OS advantage for BCS plus radiotherapy ( 0.68-0.83 for BCSS), potentially attributable to favoring healthier patients for BCS or unmeasured confounders like tumor . In , a subtype with aggressive , 5-year OS after mastectomy is approximately 84.5%, lower than 89% for BCS plus , underscoring the role of radiotherapy in locoregional control. Local recurrence rates after mastectomy are low, at 5-10% over 10 years, with most events occurring within the first 3-5 years and predominantly as regional or distant metastases rather than chest wall failures. In contrast, BCS without carries higher local recurrence (up to 30-40% at 10 years), mitigated to 5-10% with radiotherapy, yielding comparable overall recurrence patterns to mastectomy when systemic risks dominate. For mastectomy in node-positive disease, 10-year locoregional recurrence is around 8-9%, reduced further by post-mastectomy in cases with multiple positive nodes or close margins. Distant recurrence, the primary driver of mortality, occurs at rates of 9-15% within 10 years post-mastectomy, heavily dependent on efficacy rather than surgical extent.
Outcome MeasureMastectomy (Early-Stage)BCS + (Early-Stage)Key Notes
5-Year BCSS94-97%97%From data; equivalence in RCTs.
10-Year OS78-83%83-88%Observational advantage for BCS possibly confounded.
Local Recurrence (10-Year)5-10%5-10%Lower without RT in BCS; mastectomy chest wall focus.
In advanced stages (III) or , where mastectomy is often mandatory due to extensive disease, 5-year OS drops to 50-70%, with recurrence dominated by distant sites despite aggressive . Immediate post-mastectomy does not compromise oncological outcomes, with meta-analyses showing equivalent or slightly improved OS compared to mastectomy alone. These data derive largely from registries like and clinical trials, though biases in observational studies—such as in mastectomy cohorts—necessitate caution in interpreting survival differences beyond randomized evidence.

Risk Reduction in Prophylactic Cases

in women carrying or mutations, who face lifetime risks of 50-85%, has been associated with a substantial reduction in incidence, typically estimated at 90-95%. This figure derives from prospective cohort studies, such as the PROSE Study Group analysis of 251 carriers, which reported no breast cancers post-BPM over follow-up periods averaging 6-8 years, compared to expected rates yielding a of approximately 90%. Similarly, a 2017 systematic review of multiple observational studies confirmed incidence reductions ranging from 85% to 100% following BPM, attributing residual risk to incomplete tissue excision or undetected occult disease at surgery. In women from high-risk families without confirmed mutations, similarly yields at least 90% risk reduction, as evidenced by a cohort of 214 women followed for up to 14 years post-procedure, where only 2 breast cancers occurred versus 37 expected. These reductions hold across surgical techniques, though total mastectomy (removing all breast tissue) outperforms subcutaneous methods in minimizing residual glandular tissue. However, such studies are observational and lack randomized controls, introducing potential selection biases toward healthier participants opting for surgery, which may overestimate efficacy; no large-scale randomized trials exist due to ethical constraints. Contralateral prophylactic mastectomy () in women with unilateral and BRCA mutations reduces the risk of second primary cancer in the opposite by 90-97%, based on meta-analyses of registry data showing relative risks as low as 0.04 in high-genetic-risk subgroups. For instance, a analysis of 390 BRCA carriers demonstrated a 91% reduction independent of therapies. Yet, in average-risk patients without , CPM provides minimal absolute risk reduction (from ~0.5-1% annual incidence to near-zero), with no demonstrated improvement in overall or -specific survival, as contralateral events rarely drive mortality. Despite incidence benefits, and do not eliminate risk entirely, with reported post-surgical breast cancers occurring in 1-5% of cases, often in skin flaps or overlooked chest wall tissue. Long-term data indicate no consistent survival advantage over enhanced (e.g., MRI and ), as baseline mortality from prevented cancers may already be low with early detection, and surgical morbidity offsets gains in non-genetic high-risk cohorts. These findings underscore BPM's role as a targeted for genetically confirmed high-risk women, where causal reduction in tumor substrate directly lowers incidence, but emphasize individualized decision-making given unproven mortality impacts.

Patient Satisfaction and Regret Rates

In patients undergoing mastectomy, satisfaction rates vary based on reconstruction status and comparison to breast-conserving surgery (BCS). A of Breast-Q outcomes reported average with breasts ranging from 53.5 to 89 post-mastectomy , with high satisfaction in medical care and information provision. Patients opting for bilateral mastectomy without reconstruction showed 74.1% with the decision, though lower rates correlated with complications. Long-term data indicate similar breast satisfaction at 10 years between BCS with and mastectomy plus reconstruction, but mastectomy patients experience greater early declines in breast satisfaction, well-being, and sexual well-being compared to . Decision regret after mastectomy for breast cancer is generally low but influenced by surgical complications. Among women choosing mastectomy with reconstruction, mean regret scores were 4.43 on a 0-100 scale (higher indicating greater regret), with reoperations increasing regret likelihood—39% of reconstructed patients required unplanned procedures, correlating with higher dissatisfaction. For prophylactic mastectomy in high-risk women, regret rates remain low over extended follow-up. In a with 14.6-year follow-up, 5% expressed , primarily those undergoing the procedure before age 30 or without . Systematic reviews confirm most women report satisfaction, though dissatisfaction often stems from unanticipated changes or challenges rather than efficacy. In gender-affirming mastectomies (top surgery), reported regret rates are under 1% at average 3.6-year follow-up, with high satisfaction in decision-making. However, these figures derive from self-selected clinic samples using non-standardized instruments, limiting generalizability; critiques highlight potential underreporting due to social desirability bias and insufficient long-term tracking beyond typical detransition windows. Comparative surgical regret averages 14.4% across specialties, suggesting gender-affirming data warrants scrutiny for methodological rigor amid institutional biases favoring affirmative outcomes.

Controversies and Debates

Mastectomy Versus Breast-Conserving Surgery

Breast-conserving surgery (BCS), typically involving tumor excision (lumpectomy) followed by adjuvant radiation therapy, emerged as an alternative to mastectomy for early-stage invasive breast cancer following randomized controlled trials in the 1970s–1990s, such as the Milan I trial and NSABP B-06, which demonstrated equivalent 20-year overall survival rates of approximately 40–50% across stages I–II, with no significant differences in distant metastasis or breast cancer mortality. These level I evidence studies established BCS plus radiation as noninferior to mastectomy for oncologic control in tumors under 5 cm with unifocal disease amenable to clear margins. Local recurrence rates after BCS were higher without radiation (up to 30–40% at 10 years) but reduced to 5–10% with adjuvant radiotherapy, matching mastectomy's 5–15% ipsilateral recurrence risk. Recent meta-analyses of observational data, encompassing over 100,000 patients from 2010–2023, have reported superior 10–15-year overall survival with BCS (e.g., 80–86% vs. 64–79% for mastectomy in stage I–II disease), alongside lower -specific mortality ( 0.73–0.83 favoring BCS). These findings persist after for age, tumor biology, and comorbidities, though potential residual confounding from healthier BCS candidates or modern systemic therapies (e.g., targeted HER2 agents, endocrine therapy) limits causal attribution beyond RCT equivalence. subtypes influence outcomes: BCS yields comparable or better survival in hormone receptor-positive and HER2-positive cases but may underperform in triple-negative disease without adherence. Mastectomy indications include multifocal/multicentric tumors, , tumors exceeding 5 cm or >25% breast volume, diffuse microcalcifications precluding clear margins, genetic high-risk profiles (e.g., /2 mutations with bilateral risk), or patient contraindications to radiation such as or disorders. In such scenarios, mastectomy avoids radiation's 5–10% long-term cardiac/pulmonary risks and enables immediate reconstruction, though it carries higher surgical morbidity like (10–20%) and (15–25%) compared to BCS's excision-site issues. BCS generally confers superior quality-of-life metrics, including higher breast satisfaction (85–90% vs. 60–70%), psychosocial well-being, and sexual function at 1–5 years post-treatment, per prospective cohorts. Debates center on mastectomy's increasing utilization (rising 20–30% in the U.S. from 2005–2020 despite stable incidence), driven by patient anxiety, media-influenced preferences for "certainty," and contralateral prophylactic mastectomy () rates exceeding 10–15% in unilateral low-risk cases, where survival benefits are absent ( 1.0–1.1 for OS) and regret rates reach 20–30% without . Critics argue this reflects unsubstantiated by evidence, as RCTs confirm no OS advantage for mastectomy in operable disease, yet proponents cite unmeasured factors like adherence to in BCS cohorts. Selection for BCS requires multidisciplinary assessment to ensure margin-negative resection (>2 mm), as positive margins elevate recurrence 2–3-fold regardless of approach.
Outcome MetricBCS + RadiationMastectomyKey Evidence Source
10-Year Overall (Stage I–II)75–86%64–79%Meta-analyses of observational studies
Ipsilateral Recurrence (10-Year)5–10%5–15%RCTs and systematic reviews
Breast Satisfaction (1–5 Years)85–90%60–70%Prospective patient-reported outcomes

Overutilization in Prophylactic and Early-Stage Cancer

Despite equivalent oncological outcomes between breast-conserving (BCS) followed by radiation and mastectomy for early-stage (stages I-II with tumors ≤5 cm and limited involvement), mastectomy utilization remains substantial among eligible patients. National guidelines from organizations such as the prioritize BCS for such cases due to comparable survival rates and preservation of breast aesthetics. However, data from the National Cancer Database indicate that 35.5% of BCS-eligible women underwent mastectomy between 2004 and 2011, with adjusted odds increasing by 34% over that period. Bilateral mastectomy for unilateral early-stage disease exemplifies overutilization, as the lifetime risk of contralateral is approximately 10-20% but does not confer survival benefits from removal, given effective surveillance and treatment options. Rates of contralateral prophylactic mastectomy () rose from 10.4% in 2008 to a peak of 15.6% in 2013 among early-stage patients, driven partly by disclosures and anxiety rather than genetic risk or tumor biology. Although rates declined to 33% by 2020 in younger women (aged 31-40), utilization persists at levels exceeding evidence-based need, particularly among those testing negative for pathogenic variants, where rates fell from 78% pre-2016 to 67% post-guideline statements but remained elevated. Limited comprehension of low contralateral risks contributes to this pattern, with surveys showing many overestimate the preventive value of . In prophylactic contexts for high-risk women, such as /2 mutation carriers, bilateral mastectomy reduces incidence by over 90%, justifying its use in select cases with informed counseling. Yet, extension to lower-risk populations—such as average-risk women or those without identified mutations—raises concerns of overuse, as lifetime risks for BRCA carriers approach 72% by age 80, far exceeding general population rates of 12%. Prophylactic procedures in non-carriers offer minimal absolute risk reduction relative to enhanced screening, yet trends show persistent uptake influenced by broader cultural shifts toward aggressive intervention post-2013. Multiple studies underscore no survival advantage from mastectomy over BCS in early-stage disease, with some meta-analyses reporting superior overall survival with BCS ( 0.83-0.92). This discrepancy between practice and evidence highlights the need for , as mastectomy introduces avoidable morbidity without proportional benefits in low-recurrence-risk scenarios.

Evidence Gaps in Gender-Affirming Mastectomies

Gender-affirming mastectomies, often termed "top surgery," lack robust, long-term prospective studies assessing outcomes, with available evidence rated as low or very low due to methodological limitations such as small sample sizes, short follow-up periods averaging 2-3.6 years, and absence of groups. Systematic reviews of youth under 26 undergoing these procedures highlight insufficient data on sustained psychological benefits, including unresolved or comorbid conditions like and anxiety, which persist in many cases without evidence of causal resolution through surgery. The UK's Cass Review, commissioned in 2020 and finalized in 2024, concluded that evidence for gender-affirming interventions in adolescents, including mastectomy, is "remarkably weak," with no high-quality randomized or trials to evaluate efficacy against or . Regret and detransition rates remain uncertain beyond short-term self-reports, where studies report rates below 1% but rely on clinic-followed cohorts with high attrition (up to 50% loss to follow-up) and exclude non-responders or those seeking reversal elsewhere. For instance, a 2023 study of 235 patients post-mastectomy found median satisfaction scores of 5/5 at 3.6 years, yet critics note selection bias from affirming clinics and failure to track late-onset regret, which anecdotal reports from detransitioner networks suggest may emerge after 5-10 years, particularly in those with rapid-onset gender dysphoria. No large-scale, population-based registries exist to capture comprehensive regret data, unlike for other elective surgeries where regret averages 14.4%. In adolescents and young adults, evidence gaps are pronounced due to the recency of widespread adoption—U.S. procedures on those under 18 rose sharply post-2016 but remain rare (fewer than 100 annually pre-2019)—precluding 10-20 year follow-ups on skeletal maturity, , or impacts intertwined with concurrent use. Studies on youth outcomes focus on short-term relief (e.g., improved congruence at 2 years) without addressing desistance rates, which historical data for untreated show at 60-90% by adulthood. The Cass Review emphasized ethical concerns over irreversible procedures in minors, noting absent evidence that surgery outperforms multidisciplinary psychological support in preventing or improving long-term. Oncological evidence is sparse regarding post-mastectomy surveillance in transmasculine individuals, with no standardized protocols despite potential residual glandular tissue risks, and confounding factors. Overall, the field suffers from reliance on low-quality observational data from ideologically aligned sources, with calls for independent, prospective cohorts to address , as affirmed by reviews critiquing the absence of rigorous comparative effectiveness research.

Historical Development

Origins and Radical Procedures

The earliest written descriptions of breast tumors appear in the Edwin Smith Surgical Papyrus, an ancient Egyptian text dating to approximately 1600 BC (though likely copying older material from around 3000–2500 BC), which details eight cases of tumors in the breast but deems them untreated due to their progressive and incurable nature, recommending only palliative measures like cauterization rather than excision. Surgical removal of the breast, or mastectomy, emerged later in antiquity, with the first recorded attempt attributed to Leonides of Alexandria in the second century AD, involving crude excision without anesthesia or antisepsis, often resulting in high mortality from infection. By the medieval period, mastectomies were sporadically performed in Europe, typically as desperate measures for ulcerated tumors, but lacked standardization and carried prohibitive risks; for instance, 17th-century accounts describe operations using caustics or knives without lymph node involvement, reflecting limited understanding of cancer dissemination. The modern era of mastectomy began in the amid advances in and antisepsis, with early procedures focusing on tumor excision but often failing due to local recurrence from incomplete margins. In 1804, Japanese surgeon Seishu Hanaoka performed the first documented mastectomy under general using a concoction, marking a shift toward operable interventions, though still limited to simple enucleation without muscular or nodal clearance. surgeons like Richard von Volkmann in the advanced partial resections including pectoral , but recurrences persisted, prompting theories of lymphatic spread that influenced subsequent radical approaches. Radical mastectomy was pioneered by American surgeon William S. Halsted, who performed the first such operation in 1882 at , removing the entire breast, and minor muscles, and en bloc to interrupt presumed centrifugal cancer propagation via lymphatics—a hypothesis derived from animal experiments and pathological observations emphasizing local rather than hematogenous . Halsted formalized the technique in publications from 1894, advocating wide margins (up to 5–6 cm) and meticulous dissection to minimize viable cancer cells left behind, achieving reported 5-year rates of 20–40% in operable cases, superior to prior simple excisions. This procedure dominated surgery for nearly a century, justified by empirical reductions in local recurrence (from over 80% to under 10% in some series), though it inflicted severe morbidity including , shoulder immobility, and cosmetic disfigurement due to chest wall deformity. Variants like the extended radical mastectomy, introduced by in the 1950s, further escalated by including internal mammary nodes, but offered marginal gains at higher cost, underscoring the era's commitment to aggressive local control over quality-of-life considerations.

Evolution Toward Conservation and Reconstruction

In the mid-20th century, efforts to reduce the morbidity of Halsted's led to the development of the modified radical mastectomy by David Patey in 1948, which preserved the muscle while removing the breast, , and , thereby improving cosmetic and functional outcomes without compromising oncologic control. This procedure became the standard for operable through the 1960s and 1970s, reflecting a gradual recognition that en bloc resection of the chest wall was not essential for cure in most cases. The pivotal shift toward breast conservation accelerated in the 1970s through randomized controlled trials demonstrating oncologic equivalence to mastectomy for early-stage disease. Umberto Veronesi's I trial, initiated in 1973, randomized 701 women with T1 tumors to versus quadrantectomy (wide excision), axillary dissection, and ; initial results published in 1981 showed no significant difference in 8-year survival rates (85% versus 84%), challenging the dogma of total breast removal. Similarly, the NSABP B-06 trial, launched in 1976, compared total mastectomy to alone or plus in 1,851 patients with stage I/II cancer; 1985 findings in the New England Journal of Medicine indicated identical 5-year disease-free survival (75% for plus versus 77% for mastectomy), with reducing ipsilateral recurrence from 39% to 14% at 8 years. These trials, corroborated by meta-analyses, established breast-conserving surgery plus as a viable alternative by the late 1980s, prioritizing while maintaining survival parity in suitable candidates. Concurrently, evolved from rudimentary autologous transfers to reliable techniques, gaining acceptance as conservation and modified mastectomies reduced psychological burden. Early attempts, such as Vincenz Czerny's 1895 use of a autograft, were abandoned due to concerns over concealing recurrences, but gel implants, introduced for augmentation in , were adapted for post-mastectomy use in the amid improving safety profiles. Autologous flap reconstruction advanced with the revival of the latissimus dorsi myocutaneous flap for mound creation by Bostwick and Schneider in 1978, offering reliable tissue volume with lower implant dependency. The transverse rectus abdominis myocutaneous () flap, pioneered by Hartrampf in 1982, provided abundant abdominal tissue for natural contouring, marking a milestone in pedicled autologous and expanding options for immediate post-mastectomy procedures. By the , these innovations, supported by studies showing low complication rates (e.g., 5-10% flap failure for ), integrated into standard care, with uptake rising as evidence affirmed no adverse oncologic impact.

Recent Advances (Post-2000)

Since the early 2000s, nipple-sparing mastectomy (NSM) has emerged as a significant refinement over traditional techniques, preserving the nipple-areola complex (NAC) while removing all glandular tissue to minimize local recurrence risks. Initially controversial due to concerns over occult nipple involvement in cancer (estimated at 5-20% in early studies), NSM gained traction through retrospective series demonstrating oncologic safety comparable to skin-sparing mastectomy (SSM), with local recurrence rates below 5% at 5-year follow-up in selected patients without NAC involvement. Over 60 such series have been published since 2000, primarily from single-center experiences, supporting its use in early-stage breast cancer and prophylactic settings for high-risk patients, provided preoperative imaging confirms no tumor within 2 cm of the NAC. Skin-sparing mastectomy techniques have also advanced, incorporating thinner flaps and precise dissection to enhance immediate outcomes while maintaining low complication rates (e.g., skin flap necrosis under 5% in optimized protocols). These refinements, building on foundations, integrate with acellular dermal matrix (ADM) for implant support, reducing and improving projection in implant-based reconstructions, as evidenced by meta-analyses showing enhanced aesthetic scores without compromising survival. Post-2000 data from large cohorts indicate SSM/NSM enables higher patient satisfaction (over 80% reporting good-to-excellent ) when combined with autologous or implant reconstruction, though ADM use has been linked to higher infection risks in some irradiated cases (up to 10%). Robotic-assisted NSM represents a post-2010 , utilizing systems like the da Vinci SP for single-port access, which allows remote incisions (e.g., inframammary) to preserve more native skin and via nerve-sparing dissection. Feasibility studies from 2023-2024 report operative times of 2-3 hours per breast, with no in initial cohorts and reduced postoperative pain compared to open NSM, though long-term oncologic data remain pending randomized trials. Ongoing randomized controlled trials, such as those initiated in 2024, compare robotic versus open NSM for early-stage disease, focusing on metrics like sensory preservation (up to 70% innervation retention in preliminary reports) and recovery time. Integration of neoadjuvant therapies has indirectly advanced mastectomy by enabling downstaging, but surgical techniques have evolved to include oncoplastic elements in SSM/NSM for larger breasts, such as skin-reducing patterns to facilitate direct-to-implant without excessive tension. National trends show a 75% rise in post-mastectomy reconstructions from 2000 to 2020, driven by these techniques, with autologous perforator flaps (e.g., DIEP) preferred for irradiated fields to achieve durable results. Despite aesthetic gains, evidence underscores the need for rigorous patient selection to avoid disease risks, with no detriment observed in matched cohorts.

Epidemiology and Trends

Procedure Frequency and Demographics

In the United States, an estimated 140,000 mastectomies are performed annually, predominantly for therapeutic treatment of invasive , with additional procedures for prophylactic risk reduction. The rate of mastectomy among breast cancer patients has shown variability, comprising approximately 35-38% of surgical interventions for the disease from the late 1990s to early 2010s, though rates began declining after 2013 amid increased adoption of breast-conserving surgery for eligible early-stage cases. Prophylactic contralateral mastectomies among women electing unilateral mastectomy for cancer rose sharply from under 2% in 1998 to 28-30% by 2010-2012, reflecting patient preferences for symmetry and perceived risk reduction despite equivalent survival outcomes to conservation in many cases. Demographically, mastectomy recipients are overwhelmingly female, as breast cancer accounts for over 99% of indications, with male cases representing fewer than 1% of annual diagnoses (approximately 2,800 in the US). The median age at diagnosis—and thus procedure—is 62 years, with patients typically in their 50s to 70s; younger women (under 40) more frequently opt for bilateral approaches, though overall rates decline with advancing age due to comorbidities and preferences for less invasive options. Racial distributions align with breast cancer incidence, with White women comprising the majority (around 79% in studied cohorts) and highest per capita rates (133.7 per 100,000), followed by Black women (127.8 per 100,000); minority groups, including Hispanic, Asian, and Black patients, exhibit lower reconstruction uptake post-mastectomy but similar therapeutic mastectomy proportions adjusted for stage. Globally, mastectomy frequency correlates with the 2.3 million annual diagnoses, but utilization exceeds 50-77% in resource-limited settings favoring it over breast-conserving therapy due to radiotherapy access barriers, contrasting with 30-40% in high-resource Western nations. Prophylactic mastectomies remain rare overall (under 1% of total procedures in large databases), dwarfed by therapeutic indications.

Shifts in Practice Patterns

In the early 2000s, mastectomy rates for early-stage in the United States declined steadily, reflecting a broader shift toward breast-conserving (BCS) supported by randomized trials demonstrating equivalent outcomes. Between 2000 and 2006, the proportion of women treated with mastectomy decreased from 40.8% to 37.0%, with similar patterns observed from 40.3% to 35.6% between 2000 and 2005. This trend continued, with an annual decline of 2.5% from 2003 to 2016, driven by evidence from studies like the NSABP B-06 trial showing no disadvantage for BCS plus compared to mastectomy. However, mastectomy utilization reversed course around 2010, particularly for unilateral disease, due to rising rates of bilateral mastectomy and contralateral prophylactic mastectomy (). Bilateral mastectomy rates for unilateral increased from 1.9% in 1998 to 11.2% in 2011, while CPM rates rose from 4.2% in 1998 to 11.0% in 2003, influenced by heightened genetic testing awareness following BRCA1/2 discoveries in the mid-1990s and media events like Angelina Jolie's 2013 disclosure. Prophylactic mastectomy uptake among BRCA carriers and high-risk women also grew, with rates reaching 25-36% in some cohorts by the , though varying internationally from 3% to 36%. This shift occurred despite guidelines noting minimal survival benefit for CPM in average-risk s, attributed to patient preferences for reduction, symmetry, and avoidance of . Following the American Society of Breast Surgeons' 2016 position statement against routine in average-risk women, rates began declining. CPM utilization dropped 55% from 2015-2016 to 2017-2019 levels, with average-risk rates falling from 23.2% in 2017 to 13.2% by later years. Concurrently, immediate after mastectomy rose from 32% in 2010 to 58% in 2019, reflecting advances in techniques and insurance mandates like the Women's Health and Cancer Rights Act of 1998. These patterns highlight a tension between evidence-based conservation and patient-driven aggressive approaches, with overall mastectomy rates stabilizing or slightly decreasing post-2020 amid reaffirmed BCS equivalence in long-term data.