Does Staged Breast Reduction Prior to Nipple-Sparing Mastectomy Decrease Complications? A Retrospective Cohort Study between Staged and Non-Staged Techniques

Purpose: Nipple-sparing mastectomy (NSM) in patients with large, ptotic breasts continues to be a reconstructive challenge. Staged breast reduction prior to prophylactic NSM has been described to decrease complications; however, a direct comparison of outcomes between staged and non-staged techniques is lacking.

Methods: A retrospective review of all patients that underwent staged breast reduction prior to NSM was conducted. Staged cases were compared to non-staged NSM cases within the same range of breast sizes as quantified by mastectomy weight (includes breast reduction specimen weight in staged group). Non-staged cohort inclusion criteria also included similarity in risk factors for complications such as mastectomy indication, incision pattern, reconstruction type, radiation, and tobacco use at time of surgery. Staged and non-staged cohorts were compared with regards to demographics, operative characteristics and reconstructive outcomes. 

Results: Sixteen staged breast reductions (eight patients) were identified that were performed at an average of 5.2 months (range: 3.0-6.8) prior to NSM. Wise-pattern skin excision was utilized in 14 cases (87.5%) and vertical in 2 cases (12.5%) with medial (8 cases, 50%) or superomedial (8 cases) pedicles and an average reduction weight of 407 grams (range: 82-1240). Subsequently, 32 non-staged NSMs (26 patients) were identified that met inclusion criteria as matches for specific complication risk factors. There were no significant differences between staged and non-staged groups with regards to age (44.1 versus. 43.9, respectively; p=0.9960) and body mass index (25.0 versus 25.6, respectively; p=0.5648). All NSMs in both groups were prophylactic cases. There were no cases with pre- or postoperative radiation and no patients with tobacco use at the time of NSM in either group. There were no significant differences in mastectomy incisions, the majority of which were inframammary incisions (12 [75%] in the staged cohort and 28 [84.4%] in the non-staged cohort; p=0.3585).

The non-staged group had significantly more tissue expander reconstructions versus immediate implant reconstructions (24 [75%] versus 8 [24%], respectively) compared to the staged group (6 [37.5%] versus 10 [62.5%], respectively) (p=0.0249). Average mastectomy weight in the staged group was 962.1 grams (range: 544-1690) and 789.6 grams in the non-staged group (range: 540-1420) (p=0.0760). Average follow-up was longer in the non-staged group (38.5 versus 25.3 months, p=0.0446).

The rate of major ischemic complications (nipple or mastectomy flap necrosis requiring debridement) was significantly lower in the staged cohort (6.3% versus 34.4%, respectively; p=0.0404). The staged cohort also had lower rates of major mastectomy flap necrosis (0% versus 21.9%), full nipple necrosis (6.3% versus 12.5%) and explantation (0% versus 12.5%), though these complications, major/minor infection and minor ischemic complications were comparable between the groups. Two breasts in both the staged (12.5%) and non-staged (6.3%) cohorts required correction of nipple malposition (p=0.5921).

Conclusions: In patients with large breast size, staged breast reduction prior to NSM had significantly lower rates of major ischemic complications compared to non-staged cases after controlling for other risk factors for complications. Staged reduction may be a useful technique for reducing ischemic complications in prophylactic NSM cases with large breast size and an excess skin envelope.