Nipple-sparing Mastectomy

Breast Reconstruction after a Nipple-sparing Mastectomy

A nipple-sparing mastectomy is a breast cancer surgery in which the surgeon removes the breast tissue, while leaving all of the exterior breast skin as well as the nipple areola complex intact. A standard mastectomy, also known as a total mastectomy, typically involves removal of the entire breast(s), including the nipple and areola. Leaving the nipple and areola intact improves the overall look of the reconstructed breast when compared to other forms of mastectomy, giving them a more natural look and feel.  

This type of mastectomy is not appropriate for everyone though. Eligibility for nipple-sparing mastectomy depends upon the type, location and amount of cancer in the breast, as well as breast size and further treatment plans. A surgeon can evaluate a patient to determine if a nipple-sparing mastectomy would be an oncologically sound decision moving forward. Women with large tumors or tumors located near the nipple are not good candidates for this surgery. If it is determined that leaving the nipple could potentially increase risks for the patient, then the nipple will need to be removed, and the patient can have the nipple reconstructed later if she so chooses. For a successful nipple-sparing mastectomy, immediate breast reconstruction will need to be performed afterward. Combining nipple-sparing mastectomy with immediate breast reconstruction can provide an ideal aesthetic outcome and a positive psychological benefit for the patient.

Evolution of the Nipple Sparing Mastectomy

However, only recently has nipple-sparing mastectomy been accepted into the mainstream as a viable solution for the treatment and prevention of breast cancer. The nipple-sparing mastectomy has essentially been reborn in recent years. The concept of NSM was first popularized in the 1960's and 1970's. At this time, during its early stages of development, the procedure was known as subcutaneous mastectomy. Oftentimes, subcutaneous mastectomies performed in the 1970’s were more focused on optimizing the cosmetic results, and not enough concern was given to removing the maximum amount of breast tissue. In fact, a significant amount of breast tissue was often left behind intentionally to improve aesthetic result and prevent necrosis of the nipple. By the 1980's, reports of cancer recurrence in the residual breast tissue caused the procedure to fall into disfavor. 

Today however, advances in oncological safety and incision selection have made the nipple sparing mastectomy a safe and effective treatment option in carefully selected patients. Today's Nipple Sparing Mastectomy focuses on a more radical removal of breast tissue than procedures carried out in the subcutaneous mastectomy era. Surgeons now perform this procedure from a cancer prevention perspective, maximizing breast tissue removal while still maintaining the best possible cosmetic results.

Nipple-sparing Surgery Does Not Boost Recurrence

Past disfavor toward this technique stemmed largely from concerns that keeping the skin and nipple intact could increase the risk of cancer recurrence in the future. A recent study published in the journal Plastic and Reconstructive Surgery is however dispelling much of the trepidation and misunderstanding that previously surrounded nipple-sparing mastectomies over the past decades. The recent study reports that “More than 20 years of previous research shows no significant evidence of breast cancer developing after nipple-sparing mastectomy for the treatment or prevention of breast cancer.”

Cosmetic Surgery Times reports:

 “The goal of the study, led by Scott L. Spear, M.D., of Georgetown University Hospital, was to provide objective data on the risks and outcomes of the technique. The study covers 162 such procedures performed on 101 women at Georgetown University Hospital from 1989 to 2010. Seventy percent of the operations were preventive, while 30 percent were performed for treatment of diagnosed breast cancer.

 In each case, a sample of the tissue from under the nipple was analyzed before breast reconstruction was begun. Evidence of breast-cancer cells was found in 10 percent of biopsies from the women with breast cancer and in one patient undergoing preventive mastectomy. In these cases, the nipple was not used in breast reconstruction, according to an American Society of Plastic Surgeons news release.

In the patients whose biopsies showed no evidence of cancer, the tissues were used for breast reconstruction. Follow-ups showed that there were no recurrent cancers of the nipple-areola complex in women who underwent therapeutic mastectomy and no primary cancers in women who underwent preventive mastectomy. This supports previous findings that the long-term risk of cancer developing in the nipple and surrounding tissues after nipple-sparing mastectomy is, as the authors wrote, “zero or near-zero.”