Impact of Surgical Techniques, Biomaterials, and Patient Variables on Rate of Nipple Necrosis after Nipple-Sparing Mastectomy

Abstract

Background Nipple-sparing mastectomy (NSM) is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the rate of nipple necrosis after NSM is relatively high (10% to 30%). No study has specifically evaluated whether clinical and technical factors contribute to nipple necrosis after NSM. The objectives of this study were to determine the impact of clinicopathologic and surgical variables on rates of partial and total nipple necrosis after NSM and to compare overall complication rates between NSM and skin-sparing mastectomy (SSM). Methods The study included 233 cases, 113 had NSM and immediate breast reconstruction and 120 matched (for disease stage, comorbidities, and age) cases of SSM and immediate reconstruction performed at our institution from September 2003 through May 2011. Complications were analyzed using the Fisher’s exact test, and in the NSM group, clinicopathologic and surgical variables were analyzed using Rao-Scott chi-squared tests for relationship with partial or total nipple necrosis. Results The overall complication rate was 28% for NSM and 27% for SSM (p>0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate of complications was significantly higher in the NSM group than in the SSM group (26% versus 9%; p=0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the overall complication rate did not differ between the two groups. For NSM, the overall incidence of any (partial or total) nipple necrosis was 20%. There were only 2 cases (2%) with total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (34% for C cup; 6% for A and B cup; p=0.003). Smoking (p=0.08) and vascular comorbidities (p=0.09) did not reach statistical significance as predictors of nipple necrosis. The other factors analyzed were not predictors of nipple necrosis. Conclusions We found no significant difference in the overall incidence of complications in patients who have NSM compared to those who have SSM. Interestingly, the exclusion of axillary lymphatic surgery in patients undergoing risk-reducing NSM for high breast cancer risk did not decrease the incidence of complications, probably because of the inherent technical complexity of performing NSM in and of itself. Although partial nipple necrosis did occur quite frequently (19%), total nipple necrosis after NSM occurred infrequently (2%). Importantly, patients with breast size of C cup or larger had an increased risk for nipple necrosis after NSM and immediate breast reconstruction. Clinical Level of Evidence Therapeutic, III.

Endoscopy Assisted Oncoplastic Breast Surgery (EAOBS)

“…No consensuses are present for patients that would receive preoperative or post-operative radiotherapy. The results indicate that this technique can be performed in such patients (13)(14)(15).…”

“…Patients who have diabetes, vascular dis-ease and smoke have higher rates of nipple necrosis. Nipple necroses secondary to perfusion disturbance in large (Cup C and above) and overly flappy breasts also have higher rates (14,24). Most of the nipple necroses, especially partial ones, improve with medical treatment and do not require excision (21).…”

Application of Nipple-Areolar Complex Impending Necrosis with Light-Emitting Diode Treatment for Immediate Breast Reconstruction after Nipple-Sparing Mastectomy

“…The reported incidence of NAC necrosis has been reported to range from 0% to 48%. 3,4,12,13 As a result of this study, it is thought that the application of LED for minimization of NAC necrosis provides successful management. It has been found that LEDs promote wound healing, and red light having a wavelength of 640 nm has a high permeability up to 6 mm from the skin surface, thus promoting migration and proliferation of the fibroblast.…”

Nipple-sparing mastectomy in breast cancer patients: The role of adjuvant radiotherapy (Review)

“…Algaithy et al (41) and Gould et al (43) found a positive correlation between a higher rate of NAC necrosis and smoking history, type of incision, body mass index and hypertension/diabetes mellitus. The wide variation in percentage of NAC necrosis (0-28.2%) could be explained by the lack of a standardized surgical technique (6).…”