Reducing the Risk of Nipple Necrosis: Technical Observations in 340 Nipple-sparing Mastectomies

Abstract

Optimizing cosmesis is a common goal of breast surgery. In support of immediate breast reconstruction, nipple-sparing techniques have evolved. There is still a lack of agreement on the optimal technique and skin flap necrosis can be problematic. In this study, we review our experience with 340 NSM. Between March 2006 and February 2011, 340 NSMs were performed. Mammography, ultrasonography and magnetic resonance imaging were reviewed. Patient demographics and surgical techniques were reviewed. Anatomic observations were made and supported by breast images. A total of 340 NSMs in 231 patients by a single surgeon (AJS) were reviewed. Risk reduction was the indication for surgery in 59% with 50 patients (21.6%) testing positive for a BRCA1/2 gene mutation. There were two flap losses and 14 hematomas. Complete nipple necrosis occurred in three cases (0.8%) and partial loss in six patients. Recommendations are made to reduce the risk of nipple necrosis included the following: (a) preserving major perforating vessels (b) elevating skin flaps in the plane between the subcutaneous fat and the breast glandular tissue (c) the use of incisions that do not devascularize the nipple-areola complex. Nipple-sparing mastectomy can be performed with an acceptably low risk of nipple necrosis. Attention to detail including preserving major perforating vessels, elevating skin flaps in the appropriate plane and careful attention to incision planning are all required for a consistently good cosmetic outcome.

Nipple sparing mastectomy techniques: a literature review and an inframammary technique

“…Various incision locations have been described for NSMs with individual surgeons or institutions tending to favor certain approaches (23)(24)(25)(26)(27). The incisions used most frequently were best evaluated by Endara et al (26) who analyzed 48 pooled NSM studies from the literature with 41 studies describing the mastectomy incision and 11 studies evaluable for outcomes by incision type which found the most common incision used was a radial approach (46%) followed by the periareolar (27%), and the Inframammary incision (21%).…”

“…We found no studies that were designed to determine exactly how to handle the thickness of tissue left under the NAC with different surgeons applying different techniques and strategies. Studies have not been specifically controlled to determine if either everting and coring the nipple to remove all the visible ductal tissue (27,29) vs. a more conservative approach of leaving a visible rim of tissue in and around the nipple and areola (24,37) leads to better nipple viability. Petit et al (38) from Milan reported on follow-up at 5 years of 1,001 NSMs where ELIOT and intraoperative radiation, was applied to the retroareolar residual nipple tissue with excellent results (nipple necrosis rate of 3.5%).…”

“…Intraoperative pathologic evaluation of the NAC to determine preservation was initially a standard during all NSMs to determine, intraoperatively, if the NAC could be preserved in patients. This has recently been abandoned by some practices (24) due to rare instances of positive biopsies. Its use was also questioned in a poster from the ASBS registry (42) due to the low rates of intraoperative involvement (2/104 NAC biopsies) and 2 nipples removed due to false positive intraoperative results which were read as indeterminate or suspicious and were found to be cancerfree after the nipples were removed intraoperatively.…”

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

“…The indications of NSM have been extended from a prophylactic scenario and small tumors distant from the NAC to larger and multi-centric tumors (4,5). There are several studies and reviews on NSM (1,2,5-10), a number of which focus on oncological safety (3,(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24), cosmetic outcome (24)(25)(26)(27)(28)(29) and surgical techniques (24)(25)(26)(27)(28)(29)(30)(31)(32). The role of adjuvant radiotherapy (RT), including dose-fractionation concepts and techniques (6), remains unclear.…”

Nipple Pathology in Total Skin-Sparing Mastectomy

“…There appears to be no 1 ideal incision choice, and there are similar rates of nipple necrosis between radial and inframammary incisions (8.83% and 9.09%, respectively). 9,13 Although it has been universally agreed that a positive core nipple biopsy requires further removal of the NAC during surgery, 14 this dogma has been recently questioned. 15 Removal of the NAC at the time of mastectomy may compromise the blood supply to the remaining skin flap, presenting concerns for immediate reconstruction.…”