The American Society of Breast Surgeons has approved the use of nipple-sparing mastectomy for select women who are undergoing breast surgery. Nipple-sparing mastectomy is a procedure that removes the breast tissue but leaves behind the skin envelope, including the nipple-areolar complex. The incision is usually placed in the inframammary fold (along the bra line) or along the edge of the areola. In contrast, a skin-sparing mastectomy removes the nipple-areolar complex and the woman is left with a transverse scar in the middle of her breast. The volume of the breast is then reconstructed, usually with tissue expanders that can later be exchanged for permanent silicone implants.
Nipple-sparing mastectomy is a great option for some women. It can be used as a prophylactic mastectomy in women who have a strong family history of breast cancer or who carry the BRCA gene mutation. It recently has been approved for use in women with small, early-stage breast cancer if the tumor is not located close to the nipple. Unfortunately, it is not appropriate for women who are large breasted or have significant ptosis (sagginess) of the breasts. Instead, these women will benefit more from a skin-sparing technique so the breasts can be lifted and the nipple reconstructed at the appropriate position. Nipple-sparing mastectomy is discouraged in women who have history that makes them prone to develop wound healing complications. These women include smokers, diabetics, and those who have had radiation to the breast. The best candidates for nipple sparing mastectomies are young women with small-to-average sized breasts without ptosis who are undergoing the procedure for prophylaxis or because of a small early-stage breast cancer located far from the nipple.
When performed in a properly chosen patient, nipple-sparing mastectomy usually provides an excellent cosmetic outcome with well placed scars. The surgery can result in flattening of the nipple and hypopigmentation of the areola. Because of the tenuous blood supply to the nipple, wound healing complications can occur such as nipple necrosis, infection, and possible need to remove the underlying implant to allow the area to heal properly. Although the nipple-areolar complex is intact, most women will experience loss of sensation of the nipple. Obviously, since the breast tissue is removed women will not be able to breastfeed following mastectomy of any type.
Overall, the success of nipple-sparing mastectomy requires open communication between the patient, her breast surgeon, and her plastic surgeon. It requires a properly chosen patient who understands the benefits and the risks of undergoing the procedure. In such a woman, the outcome can be exceptional – from both an oncologic and a cosmetic standpoint.
