Prospective Evaluation of the Nipple–Areola Complex Sparing Mastectomy for Risk Reduction and for Early-Stage Breast Cancer

Abstract

Background Psychological effects of mastectomy for women with breast cancer have driven treatments that optimize cosmesis while strictly adhering to oncologic principles. Although skin-sparing mastectomy is oncologically safe, questions remain regarding the use of nipple–areola complex (NAC)-sparing mastectomy (NSM). We prospectively evaluated NSM for patients undergoing mastectomy for early-stage breast cancer or risk reduction. Methods We enrolled 33 early-stage breast cancer and high-risk patient; 54 NSMs were performed. NAC viability and surgical complications were evaluated. Intraoperative and postoperative pathologic assessments of the NAC base tissue were performed. NAC sensory, cosmetic and quality of life (QOL) outcomes were also assessed. Results Twenty-one bilateral and 12 unilateral NSMs were performed in 33 patients, 37 (68.5%) for prophylaxis and 17 (31.5%) for malignancy. Mean age was 45.4 years. Complications occurred in 16 NACs (29.6%) and 6 skin flaps (11.1%). Operative intervention for necrosis resulted in 4 NAC removals (7.4%). Two (11.8%) of the 17 breasts with cancer had ductal carcinoma-in-situ at the NAC margin, necessitating removal at mastectomy. All evaluable patients had nipple erection at 6 and 12 months postoperatively. Cosmetic outcome, evaluated by two plastic surgeons, was acceptable in 73.0% of breasts and 55.8% of NACs, but lateral displacement occurred in most cases. QOL assessment indicated patient satisfaction. Conclusions NSM is technically feasible in select patients, with a low risk for NAC removal resulting from necrosis or intraoperative detection of cancer, and preserves sensation and QOL. Thorough pathologic assessment of the NAC base is critical to ensure disease eradication.

Breast reconstruction at the MD Anderson Cancer Center

“…Numerous studies from MDACC and others have confirmed the oncologic safety of the conservative approaches (1,(3)(4)(5). Skin-and nipple-sparing mastectomies preserve the breast envelop, reduce scar formation, and significantly improve the aesthetic outcomes of breast reconstruction.…”

Surgical Treatment of Nipple Malposition in Nipple-Sparing Mastectomy Device-Based Reconstruction

“…However, previous studies have documented postoperative nipple malposition rates as high as 69.1 percent. 14 Various series have suggested that preoperative ptosis, 15 implants, 16 periareolar incision with lateral extension, 8,14 larger volume resections, larger tissue expander volumes, and a higher body mass index 13 may all increase the risk of malposition. Similar to past studies, we found that a periareolar mastectomy incision with lateral extension (p < 0.0001) and increased body mass index (p = 0.0093) were significantly associated with malposition.…”

“…periareolar incision with lateral extension 8,14 may be associated with subsequent nipple-areola complex malposition. In an 8-year satisfaction survey of 78 patients after nipple-sparing mastectomy, Djohan et al found that patients with larger volume resections, larger body mass index, and larger tissue expander volumes had significantly lower satisfaction rates, attributed to necrosis-related complications and malposition.…”

Nipple malposition after nipple-sparing mastectomy and expander–implant reconstruction

“…The limited scar and nipple-areola preservation gave better cosmetic results, particularly in autologous reconstruction cases, but nipple-areola malposition sometimes occurred with expander-implant reconstruction. Many surgeons seem to recognize this [5,6]. Some literature has suggested that large volume resection [7], radial incision [6,8], and breast ptosis [9] may contribute to nipple malposition.…”

“…Many surgeons seem to recognize this [5,6]. Some literature has suggested that large volume resection [7], radial incision [6,8], and breast ptosis [9] may contribute to nipple malposition. However, few reports [10] have analyzed the factors leading to nipple malposition.…”