Overview of indications for nipple sparing mastectomy

Abstract

The introduction of more targeted systemic therapies, better screening modalities with earlier diagnosis and dramatically improved reconstructive techniques has allowed more minimally invasive approaches to breast surgery. The recent introduction of nipple sparing mastectomy (NSM) has dramatically improved the cosmetic outcomes and quality of life (QoL) for patients undergoing mastectomy. This technique involves preservation of both the skin envelope including the nipple areolar complex commonly through a barely visible inframammary skin incision followed by immediate breast reconstruction. An ideal candidate includes women with small breasts, absence of ptosis, low BMI and not actively smoking. High risk patients include those with radiation treatment, active smokers, macromastia, high BMI >30 kg/m², grade 2 or 3 ptosis and active smokers. There are several new techniques to approach complex high risk patients which have expanded the candidates for NSM.

Keywords: Nipple sparing mastectomy (NSM); breast cancer; indications for NSM.

Figure 1

Ideal NSM candidate with small breasts and no ptosis. (A) Preoperative photo; (B) post bilateral NSM with direct to implant immediate prepectoral reconstruction. Photo courtesy Troy Pittman, MD. NSM, nipple sparing mastectomy.

Figure 2

Patient with BRCA gene who underwent bilateral prophylactic mastectomies. (A) Preoperative photo; (B) 5 months postoperative photo after bilateral NSM with immediate reconstruction using 410 cc prepectoral implants. Photo courtesy John Sherman, MD. NSM, nipple sparing mastectomy.

Figure 3

MedStar Georgetown University Hospital’s shave biopsy technique for management of the positive nipple margin. (A) Injection of methylene blue around borders of NAC in 4 quadrants using 25-gauge needle; (B) previous IMF incision opened and implant removed. Flap eversion with acellular dermal matrix exposed showing methylene blue demarcation in the retroareolar position; (C) acellular dermal matrix and retroareolar tissue grasped and sharply dissected within the outlined borders of methylene blue; (D) final retroareolar shave biopsy specimen. Photo courtesy Troy Pittman, MD. NAC, nipple-areolar complex; IMF, inframammary fold.

Figure 4

Patient who underwent bilateral NSM and immediate prepectoral implant reconstruction, followed by left breast postoperative radiation with an excellent cosmetic outcome. (A) Preoperative photo; (B) postoperative photo after bilateral NSM with immediate prepectoral implant reconstruction; (C) left breast after post-mastectomy radiation. Photo courtesy Troy Pittman, MD. NSM, nipple sparing mastectomy.

Figure 5

A 40 years old BRCA+ patient with grade 3 ptosis and large areola who underwent prophylactic surgery using a two-stage technique. (A) Preoperative photo; (B) post bilateral reduction-mastopexy with areolar reduction; (C) 8 weeks postop after 2nd stage bilateral NSM with immediate retropectoral tissue expander reconstruction; (D) one year postop with retropectoral final implants. Photo courtesy Troy Pittman, MD. NSM, nipple sparing mastectomy.

Figure 6

Patient with ptosis and enlarged areola who underwent bilateral NSM with DIEP free flap reconstruction using a two-stage technique. Figures show a patient with ptosis and enlarged areola who underwent DIEP free flap reconstruction from Medstar Georgetown University Hospital, also demonstrating a two-stage technique. The patient underwent initial reduction mastopexy followed by NSM with free flap reconstruction. (A) Preoperative photo; (B) post bilateral reduction-mastopexy and areolar reduction; (C) post bilateral NSM via IMF incision with DIEP free flap reconstruction. Photo courtesy Troy Pittman, MD. NSM, nipple sparing mastectomy; DIEP, deep inferior epigastric perforator.

Figure 7

A 35 years old patient s/p left lumpectomy and bilateral oncoplastic reduction followed by left breast radiation. Patient had subsequent recurrence of cancer in left breast managed with NSM and immediate DIEP free flap reconstruction, complicated by ischemia and skin necrosis in the inferior watershed area. (A) After left lumpectomy with bilateral oncoplastic reduction and subsequent postop left breast radiation; (B) left NSM with immediate DIEP flap reconstruction after recurrence of cancer 8 weeks following initial surgery. Congested, swollen flap led to skin necrosis and ischemia in the inferior watershed area. Photo courtesy Troy Pittman, MD. NSM, nipple sparing mastectomy; DIEP, deep inferior epigastric perforator.

Figure 8

A 38 years old patient with left upper outer quadrant 4 cm invasive ductal cancer and positive node, status post NAC with good response. A left NSM was performed using a lateral upper outer quadrant incision over the tumor. Patient received left breast post-mastectomy radiation therapy. Figures show patient’s left breast in various standing positions one year post-radiation with mild fibrosis, asymmetry and a high riding nipple. The patient had high overall satisfaction. (A) Front view; (B) oblique view; (C) side view. Photo courtesy John Sherman, MD and Scott Spear, MD. NAC, nipple-areolar complex; NSM, nipple sparing mastectomy.