There are several types of mastectomy procedures including Total (or simple) mastectomy which includes emoval of the entire breast, including the nipple, the areola, and most of the overlying skin; Modified radical mastectomy which is a removal of the entire breast, including the nipple, the areola, the overlying skin, and the lining over the chest muscles. In addition, some of the lymph nodes under the arm, also called the axillary lymph nodes, may be removed. The bean-shaped lymph nodes under the arm drain the lymphatic vessels from the upper arms, the majority of the breast, the neck, and the underarm regions. In some cases, part of the chest wall muscle is also removed. A Radical mastectomy requires removal of the entire breast, including the nipple, the areola, the overlying skin, the lymph nodes under the arm, and the chest muscles. For many years, this was the standard operation. However, today a radical mastectomy is rarely performed and is generally only recommended when breast cancer has spread to the chest muscles.  Some newer mastectomy procedures may offer additional options for surgery. However, further studies are needed to learn whether these procedures are as effective as more standard types of surgery in completely removing or preventing the return of breast cancer. Some of these include Skin-sparing mastectomy where the breast tissue, nipple, and areola are removed, but most of the skin over the breast is saved. This type of surgery appears to be similar to modified radical mastectomy in effectiveness for many women. It is used only when breast reconstruction is performed immediately after the mastectomy and may not be suitable for tumors that are large or near the skin surface, and Nipple-sparing mastectomy which is similar to the skin-sparing mastectomy, and it is sometimes referred to as a "total skin-sparing mastectomy." All of the breast tissue, including the ducts going all the way up to the nipple and areola, is removed, but the skin of the nipple and areola is preserved. The tissues under and around the nipple and areola are carefully cut away and examined by a pathologist. If no breast cancer cells are found close to the nipple and areola, they can be preserved. Otherwise, nipple-sparing mastectomy is not recommended.