The Nipple-Areola Preserving Mastectomy

Background: Conservative mastectomy procedures, such as the nipple-sparing mastectomy (NSM), present appealing options for patients with small invasive and non-invasive malignancies. Despite outstanding postoperative cosmetic results, nipple-areola complex (NAC) survival remains a concern. We present our two-stage nipple-areola preserving (NAP^TM) mastectomy, which aims to decrease the rate of NAC loss following conservative mastectomies.

Material and Methods: Seventy patients who underwent NSM due to malignant and benign conditions, were divided into two groups: those who underwent our two-stage NAP^TMmastectomy were matched to the group of mastectomy patients without preservation techniques. Demographic data and postoperative results were retrospectively assessed.

Technique: A transverse incision one centimeter superior to the inframammary fold (IMF) is made and the flap carefully elevated in the plane separating the subdermal adipose and breast parenchyma. Dissection then proceeds cephalad toward the NAC. After fully undermining the NAC, the plane of dissection is extended approximately 5cm medial, 5cm lateral and 2cm superior to the areolar border, resulting in a trapezoidal pocket. A 20cm x 15cm piece of 0.050cm thick non-reinforced silicone sheet is then cut to fit the dissected area and placed between the skin and the breast tissue along with a 15-French Blake drain at the bottom of the pocket.  After two to three weeks, the second stage of the NAP™ procedure, including silicone sheet removal and NSM is performed followed by immediate reconstruction.

Results: The NAP^TM group comprised 45 flaps (24 patients) and the NSM group comprised 75 flaps (46 patients), with no significant difference in terms of age, BMI or ASA score. None were actively smoking. Mean time between the delay of the flap and breast reconstruction was 17.6 days (range of 10-35 days) in the NAP^TM group. No signs of NAC vascular compromise were observed in the NAP^TM group. Nipple necrosis rates were significantly greater (p=0.0136) in the NSM group. Two patients within the NAP^TMgroup required nipple excision at the time of their mastectomies after biopsies performed at the time of the NAC delay were positive for malignancy.

Conclusion: Vascular delay, a familiar technique to plastic surgeons that improves the blood supply of a tissue following a surgical wound, results in an effective method that improves the survival of the NAC following nipple-sparing mastectomies.