Changing Perspectives in Mastectomy

CHANGING PERSPECTIVES IN MASTECTOMY: THE CASE FOR NIPPLE PRESERVATION

For decades, the recommended operation for women diagnosed with breast cancer has been a mastectomy. To reduce complications from reconstruction, more attention was given to preservation of the skin flaps, known as skin-sparing mastectomies. However, the nipple-areola complex (NAC) was routinely removed. During 2000 to 2005, only 1% of all mastectomies performed at Memorial Sloan Kettering Cancer Center in New York City were nipple sparing.¹ Before 2006, fewer than 10 nipple-sparing mastectomies (NSMs) were performed annually at Georgetown University Hospital in Washington, DC.²

In 2002, Jensen³ authored a landmark editorial questioning the practice of removing nipples in women with breast cancer, a practice that dates back well before Halsted in the early 20th century. In making his case for nipple preservation, Jensen cited the National Surgical Adjuvant Breast and Bowel Project B-06 Trial. This important study, reported in the New England Journal of Medicine,⁴ compared the effectiveness of lumpectomy, with or without radiation, versus mastectomy in women with invasive breast cancer. Jensen³ used these groups as proxies for comparing recurrence rates with and without preservation of the NACs.

Subsequently, NSMs have become more available, both for therapeutic mastectomy and risk-reducing mastectomy (popularized by Angelina Jolie).⁵ During 2018 to 2020, 22% of patients undergoing prepectoral reconstruction with tissue expanders at Memorial Sloan Kettering Cancer Center received NSMs.⁶ A 2023 systematic review found that a mean of 73 patients (32%) of patients were treated with NSMs versus 227 patients (68%) who underwent skin-sparing mastectomies.⁷ At the Mayo Clinic, which pioneered subcutaneous (nipple-sparing) mastectomies for risk reduction,⁸ NSMs increased from 24% of reconstructive cases in 2009 to 2010 to 40% of reconstructive cases in 2013 to 2014.⁹ However, adoption of NSM for immediate reconstruction remains highly variable among practices, ranging from almost none to 68% of patients.⁹

Many surgeons still routinely perform traditional mastectomies, despite studies revealing no oncologic advantage over NSMs.^10,11 Lymphatic drainage is in the direction of the deep pectoral lymphatic plexus and the axilla, not centripetal drainage toward the subareolar plexus as originally believed.¹ Nevertheless, for generations, surgeons have been taught to remove the NAC with the mastectomy specimen.

ELIGIBILITY CRITERIA FOR NIPPLE-SPARING MASTECTOMY

In 2011, Spear et al² proposed screening oncologic criteria for NSM. These criteria included a tumor size <3 cm, tumor located >2 cm from the NAC, clinically negative axillary nodes, and no skin involvement or inflammatory cancer/Paget's disease. Anatomic criteria included no excessively large or ptotic breasts. Operative requirements included a negative frozen section and negative permanent pathology.

Jensen¹² challenged this “Georgetown algorithm,” arguing that these criteria were too strict. He did not believe that large or ptotic breasts were a contraindication, nor did he believe that positive axillary nodes were a contraindication. He felt the criteria could allow tumors <4 cm, with positive or negative lymph nodes, and no skin involvement — the criteria of the B-06 trial. He did not specify a limit regarding proximity of the tumor to the NAC. Instead, he insisted on a negative frozen section and final pathology of a 1-cm subareolar biopsy. He also recommended a delay procedure to optimize the NAC blood supply. Spear¹³ replied that his criteria were not a “hard rule” and could be stretched to conserve the NAC in nonideal candidates. Spear¹³ also praised Jensen for being “ahead of the curve.”

Traditionally, very large, ptotic breasts have been considered a relative contraindication to NSM, along with a history of previous breast surgery such as a breast reduction (Fig. 1).² Other relative contraindications have included neoadjuvant chemotherapy, active smoking, obesity, radiation, and major breast or NAC asymmetry.^9,14,15 However, none of these factors is considered an absolute contraindication.^14–16 The patient depicted in Figure 1 received neoadjuvant chemotherapy, had a previous inverted-T Wise pattern breast reduction, and a tumor that was 1.5 cm from the NAC as determined on preoperative magnetic resonance imaging. A universally recognized contraindication is NAC tumor involvement.^2,9,14–18 Inflammatory breast cancer is also considered an absolute contraindication to NSM.^2,9,15–18

FIGURE 1.

This 41-year-old woman underwent a Wise-pattern inferior-pedicle breast reduction at the age of 23 years. At age of 40 years, she was diagnosed with invasive ductal carcinoma of the right breast on a routine baseline screening mammogram. She completed a course of neoadjuvant chemotherapy. A, She is seen before undergoing a bilateral nipple-sparing mastectomy with immediate placement of prepectoral tissue expanders. A targeted right axillary node dissection was performed, coincident with a bilateral NAC delay and subareolar biopsies 1 week before the mastectomies, with negative pathology. No acellular dermal matrix was used. After surgery, she completed a course of radiation therapy. B, She is seen 3 weeks after removal of the tissue expanders and insertion of smooth, round 475 mL high-profile silicone gel implants (Mentor Corp. Santa Barbara, CA), 9 months after the mastectomies and 6 months after her last radiation treatment. The nipple-sparing mastectomies and immediate reconstruction were performed by Drs Alice Chung and Jamie Zampell at Cedars-Sinai Medical Center in California. The author removed the expanders and inserted the implants at the Surgery Center of Leawood, Kansas. Nipple sensation was preserved, and the patient was highly satisfied with the aesthetic outcome. Before her nipple-sparing mastectomies, 3 other prominent cancer treatment centers had recommended bilateral mastectomies without NAC preservation.

Frey et al¹⁵ reported that NSM is a safe technique, with a rate of locoregional recurrence of 2.0%, comparing favorably with traditional mastectomy techniques. The rate of NAC recurrence was 0.4%. No patient or tumor-specific risk factor was identified for locoregional recurrence apart from a tumor-to-nipple distance ≤1 cm. However, this finding was based on only 1 patient (among 4 patients) who developed a locoregional recurrence. Three other patients developed locoregional recurrences with tumor-to-nipple distances >1 cm. A Fisher's exact test produces a nonsignificant value (P = 0.11) for this comparison among very small group sizes.

Based on radiographic and pathology findings, Dent et al¹⁹ believe that a tumor-to-nipple distance as close as 1 cm, as measured by sonography or magnetic resonance imaging, should not be considered a contraindication to NSM. The margin is treated like any other breast tumor resection margin.^14,16 The key determinant is a negative subareolar biopsy.^3,12

A delay procedure is often recommended to optimize the vascularity of the NAC and reduce the risk of necrosis (Fig. 1).^12,20–24 A subareolar biopsy is performed simultaneously. Axillary nodal status, axillary surgery, previous breast surgery (eg, a previous mastopexy or breast reduction), radiation of the breast, and tumor size are not considered contraindications to NSM in the absence of NAC tumor involvement.^16,25–27

A 2020 multicenter study examined factors related to a recommendation for NSM in a single healthcare system.²⁸ Thirty-two percent of patients received NSM. The factor with the largest impact on a recommendation for NSM was not any patient-related factor, but rather the identity of the surgeon. Frequency of NSMs varied greatly, comprising 62% (262 total cases) of mastectomies performed by one surgeon versus only 8% for another surgeon (100 total cases).

PTOTIC BREASTS

Large breasts or major ptosis are no longer considered contraindications for NSM.²⁹ Oncoplastic surgery^30–33 adopts existing mastopexy and breast reduction methods³¹ (which merit reconsideration). Alternatively, premastectomy mastopexy or reduction may be used prior to the planned NSM to improve the safety of the mastectomy.^14,34–38 Breast size is reduced, and the NAC is elevated in advance, decreasing the risk of NAC necrosis.

Traditionally, both oncoplastic surgery and premastectomy mastopexy have incorporated a Wise pattern.^{30,34,35,38,39} This method, first described by Wise⁴⁰ in 1956, removes a large area of skin and breast tissue as a horizontally oriented ellipse.^35,39 When used for a (noncancerous) breast reduction, a Wise pattern is most commonly selected.^39,41,42 An inferior pedicle is preferred by most surgeons.⁴¹ However, such a pedicle is not ideal because there is no axial blood supply oriented along an inferiorly based pedicle and all superficial circulation supplying the NAC is divided.^43,44 Moreover, this pedicle needs to be substantial — overdissection jeopardizes the viability of the NAC. An inferior pedicle also sacrifices superficial NAC innervation, impairing nipple sensation.^45,46 Tumor location may necessitate another pedicle, typically a superomedial pedicle,^30,32 which preserves the third and fourth anterior cutaneous nerve branches,⁴⁷ along with the dominant superficial circulation provided by the intercostal perforating arteries from the internal mammary artery.^48,49

A vertical mammaplasty offers geometrical advantages over a Wise pattern.^{41,43,44,50,51} A vertical elliptical resection trades width for projection, the opposite of a Wise pattern.^41,44,51 A vertical elliptical resection is ideal for almost all tumor locations in the breast and allows plenty of room for the oncologic surgeon.^31,33,37,39 Lateral and medial pillars of skin and parenchyma may be approximated in the midline providing robust closure and cover when a breast implant is inserted simultaneously.^44,50–52

Closure of a vertical ellipse provides a more conical and desirable breast shape^37,43 than a Wise pattern, which predictably produces a wide, flat shape.^41,44,50 Importantly, the base of a medially based pedicle is moved up simply by the conversion of a vertical ellipse to a straight line.^44,50 A roughly circular resection produces a 57% increase in vertical length.⁴⁴ This geometric fact means that the surgeon has less work to do to raise a ptotic NAC — 80% of the NAC lift is provided by elevation of the breast mound (Fig. 2).⁵⁰ A Wise pattern does the opposite. The superior skin flap on which a medial or superomedial pedicle is based, is pulled down.⁴¹ The NAC must be transposed a greater distance to overcome this paradoxical downward movement.^41,50

FIGURE 2.

A–D, Orientation and size-matched views of a 43-year-old woman before and 6 months after a vertical breast reduction, incorporating a medial pedicle. She was not a breast cancer patient. Her photographs demonstrate the effectiveness of a vertical mammaplasty to treat very large breasts and major ptosis, without a need for a Wise pattern resection or nipple grafting. There are no horizontal scars and no T-junctions. The tissue weights were as follows: right breast, 953 g; left breast, 1040 g. Suprasternal notch–to-nipple distances were 37 cm on the right and 38 cm on the left. Despite the severe ptosis, the preoperative right nipple displacement (nipple position relative to the apex of the breast) is only 3.77 cm. Most of the nipple elevation is provided by the breast mound elevation produced by the vertical mammaplasty. The skin lesions on the right lateral breast reveal the upward mobilization of the breast skin. BPR, breast parenchymal ratio; LPD, lower pole distance; BME, breast mound elevation. Reprinted from Swanson.⁴⁴

A vertical mammaplasty is especially useful for patients undergoing implant-based reconstruction.^51,52 The NAC is well vascularized on a widely based, short, superficial, nonbulky pedicle. The pedicle is less subject to the pressure of an implant that might jeopardize its viability, particularly if an inferior pedicle is used.⁵⁰ This approach avoids up-and-down tension on the horizontal skin closure that is created when an inframammary incision is closed in the presence of an implants or tissue expander. There is usually no inverted-T junction,³¹ which is a common site for wound breakdown, occasionally leading to implant exposure. A long horizontal scar is avoided (Fig. 2). This long scar is prone to hypertrophy and dog ears, especially where it extends medially and laterally beyond the confines of the inframammary fold.⁵³

In patients with very large breasts, the vertical method is particularly advantageous because a long, tenuous pedicle is avoided. In these patients, a short horizontal component may be required to remove the dog ear at the bottom of the mammaplasty incision.^44,51 This scar appears similar to a Wise pattern scar, but the parenchymal dissection is completely different,⁵¹ the closure is side-to-side and not top-to-bottom, and the scar is much shorter, concealed in the inframammary fold. The NAC is sited after creation of the breast mound, reducing the risk of malposition or overelevation.^44,50

A vertical mammaplasty also avoids a large exposed lower pole. By avoiding unnecessary skin resections medially and laterally, the need for lower pole support may be reduced, along with the need for any supportive mesh. Today, the off-label use of acellular dermal matrix³⁸ is ubiquitous in breast reconstruction. However, this material is known to increase the risk of complications such as seromas, infection, and red breast syndrome. The biologic product, whether obtained from cadavers or pigs, is extremely expensive. The material is nonsterile and may host donor DNA and nuclei.⁵⁴ Supportive studies are heavily affected by conflict of interest.⁵⁴

AVOIDING A NEED FOR NAC RECONSTRUCTION

Traditionally, women have been advised that they can have their NAC's reconstructed after their breast reconstruction. Patients may be informed (incorrectly) that satisfaction levels are comparable between NAC preservation and reconstruction.^55–58 Such knowledge may influence a patient to choose a skin-sparing (nipple-sacrificing) mastectomy.

Many women are exhausted, physically and emotionally, after enduring all of the various treatments needed as part of their unwelcome cancer journey (Fig. 1).⁵⁹ Once the breast mounds have been created, they have frequently undergone neoadjuvant chemotherapy, any needed staging procedure, a delay, and either a direct-to-implant immediate reconstruction or tissue expansion and have frequently undergone treatment of complications. Alternatively, they have had an autologous reconstruction.³⁶ A course of radiation treatments may be next. They are then faced with at least one, and usually more than one, procedure to reconstruct their NACs, after a delay of several months. “Reconstruction” is really a euphemism because there is no way to recreate this unique structure^5,53,60 and patient satisfaction is modest.^23,61–65 Jabor et al⁶⁴ reported that 36% of patients rated their NAC reconstructions as poor or fair. Patients most disliked, in descending order, the lack of NAC projection, color match, shape, size, texture, and position.

Plastic surgeons have traditionally focused on breast mound reconstruction. Nipple-areola reconstruction is often an afterthought. Azouz et al⁶⁶ reported that over half of plastic surgery offices in the US neither perform NAC reconstruction nor offer a referral for NAC tattooing. Preserving the nipples greatly reduces the stigmata of cancer surgery.²³ Patients with preserved nipples and reconstructed breast mounds are less likely to feel disfigured. Preservation of NAC sensation (Fig. 1), although still compromised in most women after NSM, with subjectively intact sensation in about 40% of patients,⁶⁵ is a worthy goal.

ELIMINATING NAC GRAFTING

Although some authors include patients whose nipples are grafted as NSM patients,⁶⁷ this method cannot be considered nipple-preserving surgery. Aside from postmastectomy reconstruction, NAC grafting has been used in breast reduction in women with very large breasts.⁶⁰ A popular technique in gender-affirming “top” surgery is a “double-incision” mastectomy with or without NAC grafting⁶⁸ — equivalent to breast amputation. Today, some surgeons use NAC grafting in over 90% of top surgery cases,⁶⁹ including patients with very modest breast volumes. By contrast, this author has never removed or grafted an NAC in breast reduction, gynecomastia treatment, or gender-affirming top surgery.⁵³ Vertical mammaplasty with NAC preservation on a medial pedicle makes NAC grafting essentially obsolete for these benign breast conditions.^44,50,53,60

The NAC contains smooth muscle for erectility and sensory fibers that provide erogenous sensation. Reconstructions using local flaps and tattooing are facsimiles at best. Grafted NACs barely survive on plasmatic imbibition and are prone to epidermolysis and hypopigmentation.⁶⁰ “Three dimensional” (or even “4-dimensional”)⁶⁶ tattooing makes use of shading techniques to give the illusion of 3 dimensions, but no volume or projection is possible with tattooing alone.^{60,66,70–72} The areola is flat and artificial-looking. Tattoos fade and may need touch-ups.^55,72

Nipple reconstruction with a local flap and areola tattooing is a popular alternative.^58,73,74 Photographs reveal modest nipple projection when using a local flap, as well as no projection when using a tattoo.^71,73 The texture and consistency is not like a natural nipple,⁶¹ and the projection is often lost over time.^59,61,74 Proper siting of the reconstructed NAC is challenging. The nipple should be positioned at the breast apex.⁵⁰ A reconstructed NAC positioned 20 cm from the sternal notch⁷² may appear too high on the breast. The nipple should always be positioned in relation to the breast mound, not to an extraneous landmark.

Nipple sensation is important sexually in 80% of women.⁷⁵ A 2011 functional magnetic resonance imaging study of nipple stimulation found that sensory impulses travel to the genital sensory cortex in the brain.⁷⁶ Consequently, surgeons should be reticent about removing this pleasure center. Regardless of sexual importance, sensate body parts are always preferred.⁶⁰

LIMITATIONS OF THE BREAST-Q

Commentary is needed regarding the BREAST-Q®.^77,78 This trademarked psychometric test is meant to be administered twice (reducing the inclusion rate),^58,79 before and after treatment as opposed to a single survey that asks patients to rate their results.⁸⁰ Differences in scores are presumed to be related to the treatment. Remarkably, the questions and scales comprising the cumulative 0- to 100-point scores are proprietary and unpublished, compromising transparency and the value of publications using this test. Licensees must sign a contract promising that they will not publish the questions.⁸¹ The BREAST-Q is lengthy; unanswered questions are a problem when compiling the scores.^73,79 Investigators may need to supplement a study-specific questionnaire with questions of specific interest, such as “Are you satisfied with NAC positioning?” and “Are you satisfied with the NAC appearance?”^55,73,79

Studies using the BREAST-Q to compare mastectomies frequently report no significant difference,^55–58 providing false reassurance to patients for whom NSMs are not recommended. A recent multi-author study that includes Pusic, the codeveloper of the BREAST-Q,⁸¹ cautions that the BREAST-Q “does not measure the superiority, inferiority, or equality of aesthetic outcomes” and “may be insufficiently sensitive to capture aesthetic differences with the presence or absence of a nipple.”⁵⁸ A recent meta-analysis favored NSM over skin-sparing mastectomy.⁷

It would be interesting to compare patient-reported outcomes using a patient survey that includes bottom-line questions such as “Are you satisfied with your result?” “Would you do it again?” and “Would you recommend it to others?”^55,73,80 However, equipoise may not be possible because NAC removal, regardless of the indication, is expected to provide an inferior outcome.

RISK-REDUCING SURGERY

Widely endorsed for risk reduction,¹⁶ a prophylactic NSM may be therapeutic in a small number of patients. Boyd et al⁸² reported that 4.4% of mastectomy specimens contained cancer, most frequently ductal carcinoma in situ. If a patient knows that her risk-reducing surgery does not have to be disfiguring (and may in some cases improve her breast appearance), she may be more inclined to have it.

The effect of a BRCA1 or BRCA2 mutation on the risk of breast cancer (and ovarian cancer) is well-known, increasing the lifetime risk of a breast malignancy to over 60%.^83,84 The incidence of either inherited gene mutation is 1:400 to 1:800 in the US general population (but 1:40 among people of Ashkenazi Jewish descent).⁸⁴ However, the risk of breast cancer in women even without these harmful mutations is 1 in 13 (8%).⁸⁴ Anticipating higher-quality results, more women may choose NSM to greatly reduce their lifetime risk of breast cancer.

CONCLUSIONS

A historical bias exists in plastic surgery against NAC preservation in treating both benign and malignant breast conditions.^53,60 This unique structure is often sacrificed in women with very large breasts⁶⁰ in favor of nipple grafting, which is a euphemism. This bias also extends to transgender and nonbinary patients having top surgery.⁵³

With the objective of NAC preservation in mind, increased attention must be given to the safety of operative techniques that are selected for oncoplastic procedures and staging surgery. Conventional techniques that incorporate a Wise pattern should be reconsidered in favor of vertical mammaplasties.

Many cancer centers still perform skin-sparing (nipple-sacrificing) mastectomies in the majority of cases.^2,5,7,8,28 It is time to invert this perspective and make nipple-sparing procedures the norm for benign conditions, such as breast hypertrophy and gender-affirming surgery,^53,60 and the default option for the majority of women undergoing therapeutic mastectomies and almost all women undergoing risk-reducing mastectomies.