Surgical Treatment of Nipple Malposition in Nipple Sparing Mastectomy Implant Reconstruction

Background: We report our senior author’s experience with nipple-areolar complex (NAC) malposition following nipple sparing mastectomy (NSM), surgical options for treatment, and an analysis of patient risk factors associated with malposition. (1)

Methods: A retrospective chart review was conducted on a prospectively-collected IRB-approved database of NSM cases with immediate implant-based reconstruction performed between July 2006 and October 2012. Outcomes were reviewed one year after final reconstruction. Malposition was graded according to the following scale: mild malposition (1cm displacement), moderate malposition (2cm), and severe malposition (>3cm).

Results: 319 NSMs with implant-based reconstruction were reviewed. Malposition occurred in 13.79% (n=44). Factors associated with malposition included older age (p <0.0001), increased body mass index (BMI) (p = 0.0093), preoperative sternal notch to nipple distance (p = 0.015), preoperative breast base width (p = 0.0001), use of a peri-areolar mastectomy incision with lateral extension (p  <0.0001), prior radiation therapy (p = 0.0004), prior ipsilateral lumpectomy (p = 0.0237), and postoperative nipple-areolar complex (NAC) ischemia (p = 0.0174).  Breast volume resected, implant size, use of an inframammary mastectomy incision, and single stage reconstruction had no correlation to nipple malposition.

19 (43.2%) cases were satisfied and deferred surgical intervention (9 mild, 7 moderate, 3 severe). 8 (18.2%) cases were not offered surgical intervention secondary to post-mastectomy radiation.  8 (18.2%) cases had crescent mastopexy (7 mild, 1 severe), 3 (6.8%) had implant exchange and pocket revision (1 moderate, 2 severe), 4 (9.1%) had free nipple grafts (4 severe), and 2 (4.5%) had pedicled nipple transposition (2 mild).  Of note, 2 (4.5%) of the 44 had nipple excision and reconstruction secondary to progression of disease.  There were no incidences of nipple necrosis or nipple malposition after surgical correction.  

Conclusion: NSM followed by immediate implant-based reconstruction has an identifiable risk of nipple malposition. Risk factors associated with nipple malposition included age, BMI, preoperative sternal notch to nipple distance, preoperative breast base width, mastectomy incision, prior radiation therapy, prior lumpectomy, and postoperative NAC necrosis. Various options are available to correct nipple malposition based on clinical presentation. Surgical correction of nipple malposition is a safe procedure in NSM in a well-selected population and improves overall cosmesis.