Nipple-Sparing Mastectomy: A Review of Indications, Techniques and Safety

Introduction: The debate over nipple-sparing mastectomy (NSM) continues to evolve. Recently, it has become more widely accepted, especially in the setting of prophylactic mastectomy, but its role in the treatment of breast cancer has only recently been reexamined. In this study, we present our retrospective experience with NSM, its indications, our techniques for both incision placement and pathologic analysis of the nipple/areola complex (NAC), as well as outcomes. We present our rates of neoplastic nipple involvement, and how to manage these cases, as well as complication rates including nipple necrosis. Methods: A retrospective chart review of 81 patients and 126 nipple-sparing mastectomies was performed. A total of 88 mastectomies were prophylactic (63 patients, 25 bilateral), and 38 patients had NSM performed for cancer (37 patients, 1 bilateral). Both groups were similar in terms of patient characteristics as well as incision choice (curvilinear superolateral or inferolateral). Results: After an average follow-up of 18 months, no patients had cancer subsequently develop in the NAC. In the theraputic group, 4/38 NAC (10%) had abnormal pathologic findings that led to nipple and/or NAC excision at a second stage, where in the prophylactic group, 3/88 (3.4%) were secondarily excised for delayed wound healing. No prophylactic mastectomy patients had abnormal pathologic findings on subareolar button analysis necessitating NAC excision. Additional complications included 9/126 (7%) breasts with postop erythema that was successfully managed with antibiotics. Four patients (6/126 breasts, 4.7%) underwent delayed implant removal. One patient (1/126, 0.8%) experienced postoperative implant rupture. There was 1/126 (0.8%) postoperative hematoma, and 1/81 (1.2%) patients had a postop pneumothorax (opposite the side of surgery). Conclusions: In the authors' series of nipple-sparing mastectomies performed for risk reduction or breast cancer, there was a low incidence of occult disease (3.2 percent) with no cases of locoregional recurrence .The long-term data presented here is consistent with previously published rates of nipple involvement and supports the use of nipple-sparing mastectomy in the prophylactic setting as well as in certain patients with breast cancer. Provided that certain oncologic and practical criteria are applied, it has the potential for allowing less invasive surgery and improved cosmetic outcomes without increased oncologic risk in appropriately selected patients.