22 - Nipple-Sparing Mastectomy

Abstract

Nipple-sparing mastectomy is the latest advancement in the surgical treatment of breast cancer allowing for complete preservation of the nipple–areola complex as well as the entirety of the breast envelope. The full range of reconstructive options including two-stage tissue expander-, immediate, permanent implant-, and autologous-based techniques are available after nipple-sparing mastectomy. Clinical evidence of nipple–areola complex tumor involvement represents the only current absolute contraindication to nipple-sparing mastectomy. Reconstructive considerations include various patient-, breast-, and operative-specific factors that alone carry variable risk, but in combination represent relative contraindications to nipple-sparing mastectomy. Such risk factors in nipple-sparing mastectomy include older age, elevated body mass index and mastectomy weight, preoperative radiation and chemotherapy, various mastectomy incisions, and smoking, among others. Optimal patients for nipple-sparing mastectomy are women with small to moderate-sized breasts with minimal ptosis undergoing mastectomy for prophylactic or therapeutic indications without evidence of nipple–areola complex tumor involvement. Important technical factors in nipple-sparing mastectomy include careful dissection within the anatomic mastectomy plane at the level of the superficial breast fascia. Reconstruction may then proceed after the quality and perfusion of the mastectomy flaps and nipple–areola complex are assessed clinically. In appropriately selected patients, complications after nipple-sparing mastectomy generally range from 1% to 13% with the most common being nipple–areola complex and mastectomy flap necrosis as well as infection. Ischemic complications after nipple-sparing mastectomy should be expeditiously diagnosed. Meanwhile, oncologic outcomes after nipple-sparing mastectomy, with rates of locoregional recurrence near 0.5%, are similar to those for traditional mastectomy techniques. Secondary procedures, including nipple–areola complex repositioning for malposition, may be required after nipple-sparing mastectomy, even in cases of one-stage implant or autologous reconstruction. Overall, nipple-sparing mastectomy offers excellent aesthetic and reconstructive results after breast reconstruction with improved patient satisfaction.