Implant Reconstruction in Nipple Sparing Mastectomy

Abstract

Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.

The approach for treatment for breast cancer patients is continuing to evolve toward individualized and targeted therapies, and the surgical aspect of management is no exception. Increasingly prevalent over the last two decades, preservation of the nipple-areolar complex (NAC) during mastectomy represents one of the modern evolutions in tailored ablative surgical therapy for breast cancer. ^{1 2 3} By limiting the invasiveness of the operation, nipple sparing mastectomy (NSM) has the potential to improve reconstructive outcomes, including patient satisfaction and body image. ^{4 5} However, the technical challenges of the procedure, its unique NAC-related potential complications, and the priority of oncologic safety have led to continuous efforts to better define selection criteria, refine surgical technique, and optimize oncologic outcomes.

Implant-based techniques remain the most common method for breast reconstruction after mastectomy, with over 83,000 cases performed in the United States alone in 2018. ^{6 7} When planning implant reconstruction following NSM, special considerations are made for patient selection, NSM incision, and reconstructive approach. The past few years have seen an increased interest in prepectoral implant placement and direct-to-implant (DTI) reconstruction. ⁸ This article aims at reviewing relevant selection and technical considerations for optimal implant-based breast reconstruction outcomes following NSM.

Patient Selection

Patient Variables

Nipple ischemia, necrosis, and malposition are potential adverse outcomes after NSM. Published prevalence estimates are summarized in Tables 1 and 2 . Patient selection remains a key component of minimizing NAC-related complications. Traditionally, healthy patients without known risk factors for decreased tissue perfusion and compromised wound healing capacity are considered optimal for NAC preservation. ⁹ Obesity, smoking, and poorly-controlled diabetes mellitus have all been linked to increased risk of mastectomy skin flap necrosis, delayed healing, and nipple ischemia. ¹⁰ On examination, the quality of the breast skin envelope should be noted, including elasticity, thickness, and presence of striae. The size of the breast at baseline and desired eventual reconstructive volume should be discussed, while presence of preexisting ptosis and NAC deviation should be documented. Macromastia represents a risk for not only skin and nipple necrosis but also eventual NAC malposition. ^{11 12} Any native malposition tends to become further accentuated after NSM.

Table 1. Prevalence estimates of NAC necrosis following NSM.

Authors	Year	Number of cases	Number of breasts with postoperative NAC necrosis
Salbian et al.	2019	1045	18 (1.7%)
Choi et al.	2017	1037	77 (7.4%)
Frey et al.	2017	1028	86 (8.4%)
Reish et al.	2015	605	24 (4.0%)
Small et al.	2014	319	60 (18.8%)
Colwell et al.	2014	471	21 (4.5%)

Abbreviations: NAC, nipple-areolar complex; NSM, nipple-sparing mastectomies.

Table 2. Prevalence estimates of nipple malposition following NSM, based on incision type.

Authors	Year	Total number of cases	Incision type used	Number of cases performed, by incision type	Number of breasts with nipple malposition
Choi et al.	2017	924	Lateral Radial IMF Vertical Radial Wise Pattern Lateral IMF Previous Incision Periareolar Other	244 310 131 48 143 32 13 3	21 (8.6%) 20 (6.5%) 17 (13.0%) 9 (18.75%) 8 (5.6%) 2 (6.3%) 0 (0%) 0 (0%)
Small et al.	2014	319	IMF Periareolar	311 8	36 (11.6%) 8 (100%)
Reish et al.	2015	605	Not specified	605	8 (1.3%)

Abbreviations: IMF, inframammary fold; NSM, nipple-sparing mastectomies.

While the practical indications for NSM have expanded as surgeons have gained increased experience with the technical aspects of the procedure, the classic patient considered ideal for NSM remains the young, healthy, nonsmoking woman with minimal to no ptosis. ¹⁰ Staged strategies for management of ptosis greater than grade 2, including initial or delayed mastopexy, have been described in select patients. ^{12 13 14} In implant-based reconstruction, especially with prepectoral techniques, tolerance of NAC ischemia is relatively low, and room for correction of malposition is limited. ¹⁵ The novice surgeon should exercise caution and build technical experience with strict patient selection criteria prior to broadening applications.

Prior breast incisions and local radiation before or after mastectomy are not absolute contraindications to NSM, but these patients are considered to be at a higher risk of complications. ^{16 17 18} Although no significant increase in nipple loss or other ischemic complications have been observed in patients with previous mastectomy scars undergoing implant-based breast reconstruction, concern for nipple viability may be managed with nipple delay. ^{19 20}

Oncologic Variables

Patients undergoing both therapeutic and risk-reducing mastectomies are often considered suitable candidates for NSM. ²¹ Oncologic contraindications for NSM include gross nipple involvement, Paget's disease, nipple discharge associated with malignancy, and radiographic evidence of NAC or subareolar tissue involvement. ¹ According to the National Comprehensive Cancer Network guidelines, NSM is suitable for patients with ductal carcinoma in situ (DCIS) or early stage (1 or 2), low grade (Nottingham 1 or 2), node-negative, and HER2-negative tumors without lymphovascular invasion. ²² Although randomized controlled trials are lacking, growing retrospective experience shows low rates of occult nipple involvement and local recurrence (0–3.7%) in these well-selected patient groups. ²³

Historically, a minimum distance of 2 cm was required between a patient's lesion and nipple to be considered suitable for NSM. ²⁴ However, in 2017, Dent et al published a retrospective review of 195 NSM patients who underwent implant-based reconstruction with preoperative imaging by sonography alone, magnetic resonance imaging (MRI) alone, or a combination of sonography and MRI. ²⁵ They showed that there was no difference in intraoperative nipple involvement whether a tumor-to-nipple distance cutoff of 2 cm or 1 cm was used. They concluded that a tumor-to-nipple distance of 1–2 cm by any imaging modality should not be considered a contraindication to NSM. ²⁵ Even more narrow margins have been proposed. In their 2015 prospective study of 112 NSM patients, Pozone et al found that a tumor-to-nipple distance < 0.5 cm, as measured by preoperative MRI, allows for statistically significant and clinically relevant discrimination between NAC positive and NAC negative cases. ²⁶

Regardless of the selected distance threshold, intraoperative sampling of the retroareolar tissue just deep to the NAC is a useful determinant of the appropriateness of NAC preservation, as contiguous tumor spread from the nipple occurs by way of direct extension of the retroareolar tissue into the terminal ducts. ²³ Preoperative (in the case of nipple delay) or intraoperative determination of NAC salvageability via frozen section biopsy of the subareolar tissue is often performed, with a false negative rate between 9 and 15%. ^{27 28} The use of the retroareolar margin to reflect nipple disease has yielded negative predictive values ranging from 83 to 96%. ^{28 29}

Incision Placement

Numerous incisional approaches to NSM have been described, including inframammary, periareolar, and radial (lateral or inferior vertical) incisions. Published evidence consistently supports the experienced surgeon's use of the inframammary technique, which not only maximizes cosmesis but also minimizes the risk of nipple ischemia. ^{10 30} Alternatively, a lateral radial incision anatomically preserves blood supply to the nipple and may provide better access for the novice ablative surgeon. ¹⁹ On the other hand, this incision is directly visible on the breast and can cause laterally directed retraction ischemia in the mastectomy skin flaps. ³¹ The published prevalence of nipple ischemia is variable as a result of the heterogeneity in the diagnostic definition. Complete nipple necrosis requiring surgical intervention, however, is a relatively rare event (1–5%). ^{2 21 32} Carlson et al observed a 60% prevalence of nipple ischemia associated with the periareolar incision, and calculated that the adjusted odds of nipple necrosis was 9.7 times higher with the periareolar incision relative to the other approaches used. ³² Garwood et al showed that the odds of nipple necrosis was 3.8 times higher for incisions that encompassed over 30% of the NAC circumference when compared with nonperiareolar incisions. ³³ Tolerance of nipple ischemia over a nonvascularized prosthetic is low relative to autologous tissue, especially in prepectoral implant reconstruction. ^{15 34 35} Device exposure and resultant infection may lead to complete reconstructive failure. The ischemic NAC may ultimately recover or lead to only partial necrosis, but the secondary healing process often leads to hypo or hyperpigmentation, loss of projection, distortion, asymmetry, and/or malposition ( Fig. 1 ). ¹³ Subsequent excision may be necessary, which diminishes the surface area of the breast skin envelope and may require implant downsizing.

Fig. 1.

( a ) Intraoperative photo demonstrating mastectomy skin flap and nipple–areolar complex ischemia after nipple sparing mastectomy. Immediate submuscular expander was placed after excision of areas of full-thickness thermal injury. ( b ) Nipple necrosis with ongoing demarcation by postoperative week 1. ( c ) Desquamation of partial thickness nipple necrosis by postoperative week 2. ( d ) Resolving partial thickness necrosis by postoperative week 3. ( e ) Completed tissue expansion and resolution of partial thickness nipple necrosis by two months. Sequelae of ischemia include pigmentation change, loss of projection, and lateral nipple deviation. The patient ultimately opted to complete autologous reconstruction.

Techniques and Considerations in Implant Reconstruction

Expander-Based Versus Direct-to-Implant Reconstruction

Implant reconstruction after NSM may be undertaken in a two-staged fashion with expander-implant placement or using direct-to-implant reconstruction. Expander-based reconstruction remains the most prevalent method, and there is evidence to suggest that this predictable, conservative approach is associated with the lowest complication rates after NSM when compared with direct-to-implant and other reconstructive techniques ( Fig. 2 ). ³⁶ In a retrospective cohort analysis including 1,028 NSM procedures, staged expander-implant reconstruction was associated with significantly lower rates of complete nipple necrosis (1.3%) and major mastectomy skin flap necrosis (6.5%) compared with direct-to-implant reconstruction (3.9 and 6.9%, respectively). ³⁶ When immediate expander reconstruction is undertaken, judicious selection of initial fill volume is important. While the introduction of bioprosthetic mesh has allowed for increased initial expander fill volumes over those possible with traditional total muscular coverage techniques, with the resultant benefit of reducing the amount of redundant, folded skin in NSM, higher fill volumes have also been linked to increased ischemic complication and explantation rates. ^{37 38 39}

Fig. 2.

( a ) Preoperative view of 50-year-old female with left breast ductal carcinoma in-situ undergoing bilateral nipple-sparing mastectomies. ( b ) After immediate submuscular tissue expanders were placed, serial expansion was completed to 550 ml volume. ( c ) Six months after implant exchange using smooth round silicone gel 605 ml implants.

In favorable settings where the breast skin envelope is sufficiently perfused following NSM, direct-to-implant reconstruction (DTI) is becoming a popular reconstructive approach among select patients ( Fig. 3 ). ¹⁹ This technique offers patients the potential of a single-stage reconstruction and obviates the time, effort, and discomfort of multiple visits for serial expansion. The decision to perform DTI reconstruction begins with the preoperative patient assessment. Patient selection is of the utmost importance when considering DTI. In addition to being a generally healthy, nonsmoking patient who is a good candidate for NSM, the ideal DTI patient has A- to B-cup breasts and desires breasts of approximately the same size. ^{14 40} For patients with larger breasts, the skin envelope may be sized down to accommodate DTI reconstruction. Only in the hands of an experienced surgeon should DTI breast enlargement be considered. Although considered higher-risk patients, those with prior breast incisions and radiotherapy before or after mastectomy remain candidates for DTI reconstruction. ^{16 17 18}

Fig. 3.

( a ) Preoperative view of 22-year-old female with BRCA mutation, undergoing bilateral prophylactic mastectomies. ( b ) Two weeks after bilateral nipple sparing mastectomies with immediate submuscular direct-to-implant reconstruction using 415 ml smooth round high-profile implants with lower pole bioprosthetic sling. ( c ) One year after bilateral nipple-sparing mastectomies with immediate submuscular implant reconstruction. No secondary revisions have been performed.

The first intraoperative step following NSM is to assess the skin envelope for perfusion; patients with discoloration following sizer inflation or extremely thin skin are generally not considered DTI candidates. ¹⁹ Indocyanine green laser angiography and other perfusion assessment technology have been developed as means for objective mastectomy skin and NAC viability assessment to help guide DTI reconstruction. ⁴¹

Submuscular Placement

Over the last two decades of implant-based breast reconstruction, the submuscular plane has been the most common location for device placement. Despite its original description as total muscular coverage of the prosthetic, the submuscular technique in the contemporary era is rarely used, as this approach limits implant size and has been shown to cause a suboptimal final breast shape. ¹⁹ The most prevalent technique involves partial upper pole muscular coverage and lower pole acellular dermal matrix (ADM) placement. The introduction of ADM facilitates higher initial expander fill volume with increased preservation of breast skin, precise definition of the inframammary fold, reduction of long-term capsular contracture, improved lower pole coverage, support, and expansion, and reduced patient discomfort. ^{19 39 40} The major disadvantage of submuscular placement is animation with pectoralis muscle contraction; the associated animation deformity is usually mild, but for some patients it has been noted to be severe and debilitating. ¹⁹

Prepectoral Placement

Prepectoral implant placement with ADM is regaining tremendous popularity. ⁴² Major benefits imparted by prepectoral placement include lack of animation deformity, decreased disruption of chest wall anatomy, and decreased pain. Concerns regarding early subcutaneous breast reconstruction have largely been improved upon with the use of intraoperative indocyanine green angiography for evaluation of mastectomy flap perfusion and ADM for complete soft tissue coverage of the implant. ^{43 44}

Prepectoral techniques may be associated with increased visibility of the implant in the upper pole, often requiring fat grafting to the upper pole at the time of implant exchange. The reduced thickness of the soft tissue envelope implies decreased prosthetic coverage, thereby rendering the issues of skin and NAC viability even more critical than in the submuscular setting. Emerging data shows that, compared with submuscular reconstruction, prepectoral implant reconstruction in NSM is not associated with increased complications. In a retrospective cohort study, Sbitany et al found statistically equivalent rates of overall complications between 84 cases of NSM with immediate prepectoral expander reconstruction and 186 cases with submuscular reconstruction. ¹⁵ No significant differences were observed in rates of infection, seroma, mastectomy skin flap necrosis, partial or complete nipple necrosis, or explantation. Secondary revision rates with mean follow-up of 11 months were also similar. ¹⁵

Considerations for the Ptotic Breast

Due to the increased associated risk for nipple necrosis and malposition, large and ptotic breasts have historically been a relative contraindication to NSM. ¹² Specifically, patients with grade 1–2 ptosis are the best candidates for nipple preservation, and patients with higher than grade 3 ptosis are generally considered better candidates for a staged reconstruction to optimize nipple perfusion. ^{10 19} In addition to concerns regarding blood supply, ptosis is considered a risk factor for nipple malposition following NSM. With this in mind, preoperative ptosis and NAC deviation should always be well-documented, and intraoperative adjustments such as skin-reducing approaches and NAC centralization should be made consistently.

In their 2010 study of 17 procedures, Rusby and Gui first applied the keyhole Wise incision pattern, traditionally reserved for mastopexy and reduction mammaplasty, as a means for performing skin-reducing NSM. Their patients underwent immediate tissue-expander reconstruction, and they reported one case of nipple necrosis that was successfully treated with conservative management. At a median follow up time of 9 months, all patients showed satisfactory nipple position and symmetry. ¹¹

Multiple novel approaches have since been suggested for immediate reconstruction following NSM in ptotic patients. In 2018, Pontell et al put forth a study of 8 patients with advanced ptosis, who underwent an inferior, wide-based, de-epithelized pedicle approach for bilateral simultaneous reduction mammaplasty and immediate reconstruction with either tissue expanders or autologous flaps. ⁴⁵ The average excised breast volume was 760 g. All patients with a smoking history experienced some degree of nipple necrosis, while all nonsmoking patients avoided any nipple necrosis. Postoperative complications were independent of ptosis grade, patient age, comorbidities, procedure indication, and type of reconstruction. All patients were eventually able to complete reconstructions. ⁴⁵

Staged approaches to NAC preservation is a more conservative alternative to the ptotic patient anticipating mastectomy. The treatment algorithm originally proposed by Spear et al in 2011 for staged NSM, following mastopexy and reduction mammaplasty in patients with large or ptotic breasts, was updated by Economides et al in 2019. ^{21 46} Following a retrospective review of this specific patient population between July 2011 and 2016, the authors published their findings based on 26 patients (50 breasts) with macromastic or grade 2/3 ptosis, providing an algorithmic approach for both oncologic resection and prophylaxis ( Fig. 4 ). ⁴⁶ In a 2018 study of 10 high-risk patients with either isolated grade 3 ptosis or grade 2 ptosis and diabetes, macromastia (> 1,000 g excised), BMI > 35 Kg/m ² , or prepectoral breast reconstruction, Schwartz used a staged treatment spaced over three separate operations: first, the mastectomy was performed, then the nipple repositioned, and finally the skin envelope was reduced using the keyhole Wise incision pattern. Also, a definitive implant was placed as part of the fourth operation. The patients successfully completed all four stages of reconstruction and no instances of implant loss were recorded. ⁴⁷ With a multiple-staged approach that ensures a well-perfused skin envelope and optimal nipple position prior to implant placement, even patients in this high-risk ptotic patient population remain candidates for NSM.

Fig. 4.

An algorithmic approach to both oncologic resection and prophylaxis for staged nipple sparing mastectomy following mastopexy and reduction mammaplasty in patients with large or ptotic breasts, which was adapted from Economides et al, 2019. NSM, nipple-sparing mastectomies.

Radiation

As the selection criteria for NSM have expanded, patients with a history of radiation therapy, as well as those expecting to receive post-mastectomy radiation, have increasingly been considered as candidates for NSM. In an attempt to characterize the effects of radiation timing in NSM patients, Sosin et al published a retrospective study of 40 NSM patients with a history of radiation in 2018. ⁴⁸ Nineteen patients with radiation therapy prior to mastectomy had a mean time of 5 years between radiation completion and NSM, and 21 patients who underwent postmastectomy therapy had a mean time of 24.6 weeks from NSM to first radiation dose. Following NSM, all patients underwent immediate tissue expander reconstruction and subsequent implant placement. After a mean follow-up time of 3.8 years, the authors noted a mean complication rate, operative intervention rate, and NAC survival rate of 31.6, 5.3, and 85.7% in the prior radiation group, respectively, versus 61.9, 38.1, and 100% in the post-mastectomy group. They concluded that NSM patients are less likely to have complications, require intraoperative interventions, and experience nipple necrosis when radiation is delivered prior to mastectomy compared with postoperatively. ⁴⁸

Reisch et al examined the association of post-mastectomy radiation on outcomes following NSM with immediate prosthetic or delayed-immediate expander-autologous reconstruction. ¹⁸ Amongst 605 procedures after NSM, 43 received preoperative radiation and 45 received post-mastectomy radiation. Radiation overall was associated with a higher rate of implant loss (6.8 vs. 1%, p  = 0.001). Preoperative radiation carried 2.2 times greater odds of overall complications ( p  = 0.04), while postoperative radiation was associated with a 5.6 times greater odds of explantation ( p  = 0.015). The total nipple retention rate in patients with radiation exposure was 90%, and 8% experienced reconstructive failure. While radiation was not associated with increased risk of major NAC malposition requiring excision, secondary revisions for capsular contracture treatment and fat grafting were more common after radiation treatment. ¹⁸

Following breast irradiation, implant-based reconstruction is more likely to be complicated by malposition, capsular contraction and device extrusion, making autologous tissue-based methods the preferred reconstructive approach in this setting. ³⁵ Specifically, for patients undergoing staged, implant-based reconstruction of an irradiated breast, one autologous option is the robot-assisted latissimus dorsi harvest (RALDH). In 2012, Selber et al published a feasibility case series study of 7 patients, showing that robotic harvest of the latissimus dorsi avoids the unsightly scars associated with the traditional open approach, offers technical advantages over an endoscopic approach, and is as effective as other approaches. ³⁵ Clemens et al followed this study with their 2014 retrospective analysis comparing patients with a history of breast irradiation. They underwent a two-staged implant-based reconstruction with a latissimus dorsi flap; 12 patients underwent RALDH and 64 patients underwent traditional open technique. ³⁴ The first stage consisted of a skin-sparing mastectomy with immediate tissue expander placement. The second stage involved reconstruction with latissimus dorsi muscle flap and permanent implant placement at an average of 7.1 months after completion of radiation. Complication rates were 16.7% in RALDH versus 37.5% in open harvest, including significantly higher rates of seroma, infection, capsular contracture, and delayed wound healing associated with the open approach. ³⁴ Particularly in the subset of patients with a history of breast irradiation, these studies indicate that robot-assisted reconstruction using a latissimus dorsi flap is a safe approach, which is associated with minimal scarring and high patient satisfaction; this technique may be particularly applicable to patients with total skin and NAC preservation.

Given the increased risk of postoperative complications after NSM and implant reconstruction in the setting of radiation, caution should be exercised in this patient population. Secondary revisions are often necessary to address implant or NAC malposition. ⁴⁹

Neoadjuvant Chemotherapy

For breast cancer patients with locally advanced disease requiring neoadjuvant chemotherapy, NSM has been suggested as a safe, complementary surgical treatment modality. ^{50 51} In 2019, Bartholomew et al published a retrospective study of 832 breasts, 88 (10.6%) of which received neoadjuvant chemotherapy followed by surgical intervention and 744 of which received primary surgical intervention. ⁵² No significant differences were found between these patient populations with regard to 30-day surgical complication rates, including NAC or skin flap necrosis, infection, wound dehiscence, and hematoma/seroma. They also found no correlation between postoperative complication rates and the time interval between chemotherapy and surgical intervention. ⁵² In their 2015 study, Santoro et al also showed comparable complication rates between patient groups completing neoadjuvant chemotherapy and those undergoing primary surgery. ⁵³ Together, these results indicate that, at least, in the acute post-operative period, patients completing neoadjuvant chemotherapy should be considered as candidates for NSM, barring other contraindications.

Nipple Malposition

One of the most challenging adverse outcomes of NSM is nipple malposition. Depending upon the diagnostic criteria, between 7 and 14% of patients experience NAC malposition after NSM. ^{54 55} Risk factors for malposition include macromastia, ptosis, preexisting NAC deviation or asymmetry, and ptosis. ⁵⁵ Previous lumpectomy, mastectomy incisional contraction, delayed healing, and mastectomy skin flap necrosis may also contribute to malposition. ⁵⁴ Superior and lateral deviations represent the most common malposition patterns. ^{54 56} Choi et al published a 2017 review of 1,037 cases of NSM with the full spectrum of reconstructive options performed, and only 7.4% underwent NAC repositioning. ⁵⁴ Following multivariate analysis, independent risk factors for NAC repositioning included preoperative radiation, vertical radial mastectomy incisions, and autologous reconstruction. Implant-based reconstruction was a negative predictor of r-positioning, although this finding may be a function of selection bias, reflecting surgeon reluctance to perform re-positioning in implant-based cases. ⁵⁴

Measures that can be taken during immediate reconstruction to minimize NAC deviation include suturing the base of the NAC to the pectoralis during submuscular reconstruction, using external occlusive dressings to minimize tangential movement of the skin envelope over the device, and placing drains judiciously to both generate internal negative pressure and limit tangential glide. ⁵⁷ Thoughtful selection of optimal device dimensions is paramount. The base width of the implant should be carefully chosen, so as to optimize centralization of the nipple; if an implant is too narrow, the nipple will be lateralized. The height of the device relative to the chest wall and nipple position should be taken into consideration to ensure correspondence of the latter with the point of maximum implant projection. Implant reconstruction, particularly in the prepectoral plane, limits the extent to which nipple malposition may be safely corrected, rendering the initial management of NAC position during immediate reconstruction critical. ¹⁹ Remedial options include crescentic excision, pedicled transposition flaps, pocket adjustments, and free nipple graft; however, these need to be tailored to the individual patient, degree of malposition, and other specific reconstructive circumstances. ^{54 55}

Patient Satisfaction

In 2016, Dossett et al performed a prospective study of 38 patients undergoing NSM. ⁵⁸ Pre- and postoperative body image and quality of life (QoL) were measured using validated tools—the Breast Evaluation Questionnaire and the Body Image after Breast Cancer Questionnaire. ^{59 60} NAC and skin sensation were evaluated using the Semmes Weinstein Monofilament test. NSM patients were generally satisfied with their postoperative body image and QoL, but NAC sensation was only preserved bilaterally in 26% of patients and unilaterally in 68% of patients. In addition, patients were not satisfied with their postoperative level of sexual arousal with breast or nipple stimulation. ⁵⁸ In their 2016 prospective observational study of 63 patients undergoing NSM, Chehade et al reported on QoL outcomes at a mean follow-up time of 27.6 months. ⁶¹ Their patients had a mean BREAST-Q outcome score of 88%, which equates to a high level of satisfaction. The authors also reported a postoperative subjective (completed by the patient) and objective (completed by an independent observer) aesthetic assessment of 9.2/10 and 9.3/10 respectively. ⁶¹ Other than a high likelihood of dissatisfaction surrounding post-NSM nipple sensation, patient attitude toward NSM is consistently positive, and satisfaction is high.

Oncologic Outcomes

Despite the increasing popularity of NSM, concern persists regarding its oncological safety, as residual breast tissue could harbor occult malignancy or serve as a source for future malignant growth. A 2015 meta-analysis by De La Cruz et al consisted of 5,594 total patients in studies comparing NSM outcomes to those following either skin-sparing mastectomy (SSM) or modified radical mastectomy (MRM). ⁶² According to their analysis, in studies with a mean follow-up time > 5 years, the overall survival rate, disease-free survival rate, rate of local recurrence, and rate of nipple-areolar recurrence reported for NSM were 86.8, 76.1, 11.4, and 3.4%, respectively. When comparing each of these outcome variables to both SSM and MRM, they found no significant risk differences between these subgroups but noted a trend in favor of NSM in all outcome categories. ⁶² In their 2018 systematic review comparing 1,419 NSMs to 1,596 SSMs, Agha et al also reported no statistical difference between these procedures with regard to both mortality and local recurrence. ⁶³

In a retrospective 2019 study, with a mean follow-up time of 62 months, investigating patients who underwent therapeutic NSM followed by immediate reconstruction, 59 patients (tumor-to-nipple distance of < 2.0 cm) were compared with 134 patients (tumor-to-nipple distance of > 2.0 cm). ⁶⁴ There were no significant differences found between these groups with respect to ER, PR, HER2-neu status, or nodal involvement. The 10-year disease-free survival was 93.2% in the < 2.0 cm group and 96.3% in the > 2.0 cm group, with no statistically significant difference shown ( p  = 0.368). ⁶⁴

Collectively, these studies indicate that NSM reconstruction in well-selected patients is an oncologically sound procedure compared with other mastectomy techniques.

Conclusion

Nipple preservation during mastectomy is increasing in popularity due to apparent oncological safety, favorable reconstructive outcomes, and improved associated patient body image. A wide variety of implant-based techniques are suitable for reconstruction after NSM. In select patients and with the proper technique, nipple sparing mastectomy is a safe alternative in both prophylactic and therapeutic settings.