Purpose: Removal of the nipple-areolar complex (NAC) during mastectomy is the current standard of care. There is a recent trend towards nipple/areola skin preservation in selected patients. We evaluated the efficacy of total skin-sparing mastectomy (TSSM) and immediate reconstruction.

Methods: 39 patients underwent 59 TSSM at UCSF from January 2002 to January 2005. MRI excluded patients with disease within 2 cm of the nipple, involving skin or large central tumors. Intra-operative frozen sections were performed to confirm that the NAC was tumor-free.

Results: A variety of techniques, including implants (n=27), tissue expanders (n=7), pedicled TRAM flaps (n=14), latissimus dorsi flaps (n=1), DIEP flaps (n=9) and SIEA flaps (n=1) were used. 71% had superficial epidermolysis post-operatively which resolved within 3 weeks, yielding excellent long-term cosmetic results. Two patients experienced bilateral nipple skin loss. Two specimens were found to have DCIS, and these were subsequently removed.

Conclusions: Preservation of the entire skin envelope allows for a true single-stage reconstruction. Because of the significant rate of partial necrosis with this technique, implant reconstruction should be performed cautiously and autogenous tissue should be considered. Additionally, muscle-sparing flaps such as the DIEP or SIEA provide superior aesthetic results, with limited morbidity and shorter recovery times.