Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications

Abstract

Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0-3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment. Indications are carcinoma or DCIS that require mastectomy (including after neoadjuvant chemotherapy). NSM is also suitable for women undergoing risk-reducing bilateral mastectomy. Tumor not less than 2cm from the NAC is recommended, but may be less important than no evidence of nipple involvement on mandatory intraoperative nipple margin assessment. A positive margin is an absolute contraindication for nipple preservation. Other contraindications are microcalcifications close to the subareolar region and a positive nipple discharge. Complication rates are similar to those for other types of post-mastectomy reconstructions. The main complication of NSM is NAC necrosis, however as surgeon experience matures, frequency declines. Factors associated with complications are voluminous breast, ptosis, smoking, obesity, and radiotherapy. Since the access incision is small, breast tissue may be left behind, so only experienced breast surgeons should do these operations; close collaboration with the plastic surgeon. For breast cancer patients requiring mastectomy, NSM should be the option of choice.

Nipple sparing: standard of care?

“…Patients who are obese or have multiple medical co-morbidities are not ideal candidates for NSM due to the increased risk of complications with complex surgery, reconstruction, and the associated longer operative time. However, in recent years, NSM has been used more widely in groups previously excluded from consideration, for example, in selected patients following neoadjuvant chemotherapy, and in those with prior breast incisions or macromastia 3,7 .…”

“…Preservation of the NAC has been associated with improved body image, satisfaction with nipple appearance and sensitivity, and higher psychosocial and sexual well-being in patients who undergo NSM compared with SSM 1,2 . Recent studies have confirmed the oncologic safety of NSM and its successful application for risk reduction in patients at high risk for breast cancer [3][4][5] . Complication rates in recent years are comparable to those for other types of post-mastectomy reconstruction, likely a result of improving surgeon experience and wider application of NSM technique 3,5 .…”

“…Recent studies have confirmed the oncologic safety of NSM and its successful application for risk reduction in patients at high risk for breast cancer [3][4][5] . Complication rates in recent years are comparable to those for other types of post-mastectomy reconstruction, likely a result of improving surgeon experience and wider application of NSM technique 3,5 . Given the continuously increasing rates of bilateral mastectomy and high demand for breast reconstruction 6 , we must ask whether NSM should now be considered standard of care.…”

Tissue engineering and regenerative medicine strategies for the female breast

“…Synthetic prosthesis has some shortcomings, such as infection of the surrounding tissues, wound dehiscence, capsular contracture, variations in shape, dislocation from the implant site, calcification, or even a further rupture of the prosthesis itself (Galimberti et al, ). In the worst case, the patient requires a replacement of the implant through additional surgery.…”

Identifying the dissection plane for mastectomy—description and visualization of our technique

“…The optimal surgical plane provides the surgeon with a better overview of the operative field (12), resulting in adequate resection of breast parenchyma to obtain the best oncological outcome, while retaining the maximum amount of subcutaneous adipose tissue on the skin flaps to achieve the best aesthetic results (7,8,13,14). In this visualized surgery paper, we present our experience identifying the dissection plane using hydrodissection through an inframammary incision.…”