Background:
Necrosis of the nipple-areolar complex (NAC) or surrounding skin has been reported in 6%–30% of nipple-sparing mastectomy (NSM) patients, with higher rates associated with larger breasts, previous breast surgery, previous radiation, and active smoking. The nipple delay (ND) procedure is known to improve viability of the NAC in NSM patients with high-risk factors.
Methods:
A single-institution retrospective review was done of patients who underwent ND and NSM or NSM alone from 2012 to 2022. Patient demographics, risk factors, and outcomes were compared.
Results:
Forty-two breasts received ND-NSM and 302 breasts received NSM alone. The ND-NSM group had significantly more high-risk factors, including elevated BMI (26.3 versus 22.9; P < 0.001), elevated prior breast surgery (50% versus 25%; P < 0.001), and greater mastectomy specimen weight (646.6 versus 303.2 g; P < 0.001). ND-NSM was more likely to have undergone preparatory mammoplasty before NSM (27% versus 1%; P < 0.001). There was no delay in NSM treatment from decision to pursue NSM (P = 0.483) or difference in skin necrosis (P = 0.256), NAC necrosis (P = 0.510), hematoma (P = 0.094), seroma (P = 0.137), or infection (P = 0.437) between groups. ND-NSM and NSM patients differed in total NAC necrosis (0% versus 3%) and implant loss (0% vs 13%), but not significantly.
Conclusions:
We demonstrated no NAC necrosis and no significant delay of treatment in higher risk ND-NSM patients. ND may allow higher risk patients to undergo NSM with similar morbidity as lower risk patients.
Takeaways
Question: Does the nipple delay (ND) procedure decrease the surgical morbidity for higher risk patients undergoing nipple-sparing mastectomy (NSM)?
Findings: In a single-institution retrospective review of higher risk patients who underwent ND and NSM and lower risk patients who underwent NSM alone, we found that there was no difference in delay in NSM treatment or in rates of skin necrosis, NAC necrosis, hematoma, seroma, or infection between the groups.
Meaning: ND procedures, often with preparatory mammoplasty, may make more patients candidates for NSM while maximally protecting the viability of the NAC.
INTRODUCTION
Skin-sparing mastectomy and nipple-sparing mastectomy (NSM) are common approaches for patients who are undergoing breast cancer treatment or who have increased risk of developing breast cancer due to genetic susceptibility. NSM with reconstruction can provide women with an optimal reconstructive aesthetic outcome and has been increasing in popularity in the last decade. The nipple-areolar complex (NAC) is an important aspect of a patient’s positive body image.1 Nipple reconstruction has been shown to improve the psychosocial and sexual well-being in women who have undergone breast reconstruction.2 NSM does not come without risks, however, as necrosis of the NAC or surrounding skin flaps has been reported from 6%–30% of patients undergoing NSM.3–5 Increased rates of NAC necrosis have been associated with various risk factors, including ptotic breasts, periareolar scars, large cup size, and previous radiation.6,7
Several studies have shown that the use of a nipple delay (ND) procedure improves viability of the NAC in NSM patients.5,8–11 The ND procedure separates the NAC from the underlying breast parenchyma approximately 2 weeks before the NSM procedure to improve the collateral vascular supply of the NAC before the mastectomy. Preparatory mammoplasty can convert patients with moderately large and/or ptotic breasts into better candidates for NSM,12 but creates scars that may jeopardize NAC viability with NSM (Fig. 1). ND may be particularly useful in mitigating risk in these patients. We report our institutional experience with the ND procedure before NSM compared with standard NSM.
Fig. 1.
Mammoplasty or other breast procedures may involve incisions that impact viability of the NAC in subsequent NSM procedures. Incisions around the nipple such as the (A) periareolar and (B) wise incisions pose significant risk for NAC necrosis. Other incisions such as (C) inframammary and (D) lateral may also pose a risk if significant dissection is performed.
METHODS
Indications
A retrospective review was performed of all patients at the University of Pittsburgh Medical Center who underwent NSM from 2012, the time we started incorporating ND into our practice, until 2022. NSM candidates included patients requiring mastectomy due to diagnosed breast cancer and/or high genetic susceptibility with the desire to preserve their NAC. Preoperatively, patients were informed of their reconstructive options. Candidacy for NSM was determined by the oncologic surgeon based on the patient’s breast tumor characteristics. If the oncologic surgeon thought it necessary to biopsy the NAC, the biopsy was done during the ND procedure. Patients with NAC biopsy demonstrating malignant cells were offered non-NSMs. Patients who were candidates and desired NSM but had significant ptosis or large breast volume underwent preparatory mammoplasty to optimize breast dimensions for NSM and reconstruction. Beginning in June 2012, these types of patients, as well as others with breast scars, history of radiation, and/or prior or current smokers who were deemed higher risk for NAC complications, were also offered ND 2 weeks before NSM.
Nipple Delay Technique
A 5-cm inframammary incision was made, and the skin was elevated in the mastectomy plane from inferior to superior until the NAC was undermined with a 1-cm border (Fig. 2). No silicone sheet or alternative product was used as an interposition in the mastectomy plane. A retroareolar biopsy was performed for permanent pathologic analysis, if indicated by the surgical oncologist, and the incision was closed. If the retroareolar biopsy was negative, the patient returned in 2–3 weeks for NSM and reconstruction.
Fig. 2.
NSM with ND technique. NSM technique involves (A) a 5-cm inframammary incision with subsequent (B) skin elevation in the mastectomy plane from the inferior to superior pole. C, The area is undermined with a 1-cm border around the NAC with (D) careful dissection of the overlying skin from the breast parenchyma.
Outcome Measures
Patient characteristics were collected, including age, body mass index (BMI), smoking status, comorbidities, bra size, breast ptosis, prior breast surgery and scars, prior radiation, reason for mastectomy, type of reconstruction, preparatory mammoplasty specimen weights, and mastectomy specimen weights. Patient outcome measures were classified as either major complications, requiring surgical treatment or admission to the hospital, or minor complications including delayed healing and seromas that did not require surgical intervention and infections that did not require hospitalization. Types of complications encountered included hematoma, seroma, NAC necrosis, mastectomy skin flap necrosis, implant or tissue expander loss, bleeding, infection, and flap complications.
Statistical Analysis
Statistical analysis of the two study groups was performed for data points of interest. For linear variables, a two-sample t test was utilized, and Pearson’s χ2 test was used for nonlinear variables. A two-tailed P value of less than 0.05 was considered significant. Statistical calculations were performed in Microsoft Excel (Microsoft Corp., Redmond, WA).
RESULTS
Patient Characteristics and Oncologic Data
From 2012 to 2018, 22 patients underwent the ND and NSM procedures, of which 20 were bilateral and two were unilateral (42 breasts). We reviewed 175 patients who underwent NSM only, of which 127 were bilateral and 48 were unilateral (302 breasts). No statistical difference existed between patients in the ND-NSM group and NSM-only group in average age, race, smoking status, diabetes mellitus, and other comorbidities (Table 1). Most common comorbidities included hypothyroidism, hypertension, anxiety, depression, and asthma. Patient BMI in the ND-NSM group was higher (26.3 ± 3.85) than in the NSM-only group (22.9 ± 3.12) (P < 0.001) (Table 1).
Table 1.
Demographics and Patient Characteristic Data
| ND + NSM | NSM | P | ||||
|---|---|---|---|---|---|---|
| Parameter | Patients (n = 22) | Breasts (n = 42) | Patients (n = 175) | Breasts (n = 302) | By Patient | By Breast |
| Age (y) | 48.6 ± 7.0 | 46.4 ± 9.7 | 0.297 | |||
| BMI (kg/m2) | 26.3 ± 3.85 | 22.9 ± 3.12 | <0.001* | |||
| Race, n (%) | ||||||
| White | 21 (95.5) | 170 (97.1) | 0.598 | |||
| Asian | 1 (4.5) | 3 (1.7) | ||||
| Black | 0 (0) | 2 (1.1) | ||||
| Smoking, n (%) | ||||||
| Never | 18 (81.8) | 118 (67.4) | 0.327 | |||
| Former | 4 (18.2) | 50 (28.6) | ||||
| Active | 0 (0) | 7 (4.0) | ||||
| Diabetes, n (%) | 0 (0) | 2 (1.1) | 0.614 | |||
| Comorbidities†, n (%) | ||||||
| 0‐2 | 18 (81.8) | 157 (89.7) | 0.268 | |||
| >2 | 4 (18.2) | 18 (10.3) | ||||
| Any breast surgery, n (%) | 16 (72.7) | 28 (66.7) | 45 (25.7) | 59 (19.5) | <0.001* | <0.001* |
| Remote breast surgery | 11 (50.0) | 18 (42.9) | 43 (24.6) | 55 (18.2) | <0.001* | <0.001* |
| Preparatory mammoplasty | 8 (36.4) | 12 (28.6) | 2 (1.1) | 4 (1.3) | <0.001* | <0.001* |
| Ptosis‡, n (%) | n = 30 | n = 200 | <0.001* | |||
| Grade 0 | 2 (6.7) | 49 (24.5) | ||||
| Grade 1 | 4 (13.3) | 88 (44.0) | ||||
| Grade 2 | 16 (53.3) | 55 (27.5) | ||||
| Grade 3 | 6 (20.0) | 6 (3.0) | ||||
| Pseudoptosis | 2 (6.7) | 2 (1.0) | ||||
| Indication, n (%) | ||||||
| Therapeutic | 11 (26.2) | 148 (49.0) | 0.006* | |||
| Prophylactic | 31 (73.8) | 154 (51.0) | ||||
Statistically significant.
Other comorbidities include any documented chronic condition.
Only from charts with recorded ptosis.
Former smoker, quit date >6 weeks before surgery; active smoker, quit date <6 weeks before surgery.
Any prior breast surgery includes remote and/or preparatory breast surgery.
Nearly twice the percentage of ND-NSM patients underwent a remote breast surgery compared to NSM patients (50% versus 25%; P < 0.001). The difference in rates of preparatory breast surgery, done to optimize candidacy for NSM, was significant between the ND-NSM group and NSM-only group (27% versus 1%; P < 0.001) (Table 1).
A greater portion of ND-NSM patients had a genetic predisposition to breast cancer compared with NSM patients (68% versus 48%; P < 0.001). Meanwhile, fewer ND-NSM patients were diagnosed with breast cancer compared to NSM patients (46% versus 80%; P < 0.001). The ND-NSM and NSM group patients did not differ in cancer staging, chemotherapy, hormone therapy, or breast radiation (Table 2).
Table 2.
Oncologic Data
| ND + NSM | NSM | P | ||||
|---|---|---|---|---|---|---|
| Parameter | Patients (n = 22) | Breasts (n = 42) | Patients (n = 175) | Breasts (n = 302) | By Patient | By Breast |
| Cancer diagnosis, n (%) | 10 (45.5) | 140 (80.0) | <0.001* | |||
| Cancer stage, n (%) | ||||||
| 0 | 2 (20.0) | 32 (22.8) | 0.307 | |||
| 1 | 3 (30.0) | 46 (32.9) | ||||
| 2 | 3 (30.0) | 56 (40) | ||||
| 3 | 2 (20.0) | 6 (4.3) | ||||
| 4 | 0 (0) | 2 (1.4) | ||||
| Chemotherapy, n (%) | 0.250 | |||||
| Neoadjuvant | 3 (13.6) | 46 (26.3) | ||||
| Adjuvant | 1 (4.5) | 17 (9.7) | ||||
| Hormone treatment, n (%) | 6 (27.3) | 69 (39.4) | 0.268 | |||
| Radiation, n (%) | ||||||
| Previous | 2 (9.1) | 2 (4.7) | 13 (7.4) | 13 (4.3) | 0.752 | 0.516 |
| PMRT | 1 (4.5) | 1 (2.4) | 16 (9.1) | 16 (5.3) | ||
Statistically significant.
PMRT, post-mastectomy radiation therapy.
Breast Examination and Surgical Details
The ND-NSM group had statistically significant greater ptosis and heavier mastectomy specimen weights than the NSM-only group. Ptosis information was available for 30 of 42 ND-NSM breasts and 200 of 302 NSM breasts due to differences in surgeon preoperative physical examination notes. Most breasts in the ND-NSM group had higher ptosis grades (54% grade 2 and 20% grade 3), and fewer had lower ptosis grades (7% grade 0, 13% grade 1, and 7% pseudoptosis). Most breasts in the NSM group had lower ptosis grades (25% grade 0, 44% grade 1, and 1% pseudoptosis), while fewer had higher ptosis grades (28% grade 2 and 3% grade 3) (Table 1). Average original total breast volume, defined as the preparatory reduction volume and mastectomy volume, of all patients in the ND-NSM group was heavier compared to patients in the NSM group (646.6 ± 381.5 g versus 303.2 ± 131.9 g; P < 0.001). The mastectomy weight specimens were also heavier in the ND-NSM group than in the NSM group (503.9 ± 193.8 g versus 303.2 ± 131.9 g; P < 0.001) even after mammoplasty (Table 3).
Table 3.
Surgical Data
| ND + NSM | NSM | P | ||||
|---|---|---|---|---|---|---|
| Parameter | Patients (n = 22) | Breasts (n = 42) | Patients (n = 175) | Breasts (n = 302) | By Patient | By Breast |
| Mastectomy laterality, n (%) | ||||||
| Unilateral | 2 (9.1) | 48 (27.4) | 0.064 | |||
| Bilateral | 20 (90.9) | 127 (72.6) | ||||
| Mastectomy incision, n (%) | ||||||
| IMF | 40 (95.2) | 270 (89.4) | 0.203 | |||
| Periareolar | 2 (4.8) | 11 (3.6) | ||||
| Other | 0 (0) | 21 (7.0) | ||||
| Original total breast volume (grams) | 646.6 ± 381.5 | 303.2 ± 131.9 | <0.001* | |||
| Mastectomy weight (grams) | 503.9 ± 193.8 | 303.2 ± 131.9 | ||||
| Preparatory mammoplasty weight (grams) | 420.1 ± 267.8 | N/A | ||||
| Reconstruction, n (%) | ||||||
| Tissue expander | 29 (69) | 186 (61.6) | 0.177 | |||
| LD + tissue expander | 0 (0) | 9 (3.0) | ||||
| Direct to implant | 7 (16.7) | 83 (27.5) | ||||
| Autologous | 6 (14.3) | 24 (7.9) | ||||
Statistically significant.
IMF, inframammary; LD, latissimus dorsi; N/A, not applicable.
There was no statistical difference in NSM incisions, as most were in the inframammary fold for both ND-NSM and NSM groups (95% versus 89%; P = 0.064). There was no difference in types of reconstruction, with most patients in the ND-NSM and NSM-only groups undergoing a two-stage reconstruction with tissue expanders and implants (69% versus 62%; P = 0.177) (Table 3).
Eight prophylactic patients in the ND-NSM group underwent a preparatory staging mammoplasty and ND surgery to optimize candidacy for NSM with an average time between the preparatory mammoplasty and ND procedure of 109.5 ± 60.6 days with a range of 70–266 days. The average time from the ND to NSM was 16.1 ± 4.1 days with a range of 10–28 days. To determine the average delay in NSM treatment in patients with breast cancer, the time between plastic surgery consult and NSM was calculated for breast cancer patients only, and patients undergoing neoadjuvant chemotherapy and preparatory mammoplasty were excluded. There was no significant delay from plastic surgery consult to NSM (P = 0.483) when comparing six ND-NSM patients (42.2 ± 18.9 days, range 20–69 days) and 96 NSM (37.1 ± 17.0 days, range 6–99 days) patients.
Complications
The average length of follow-up after NSM for both groups was 14.5 ± 15.8 months. The average follow-up time was 2.8 ± 5.9 months in the ND-NSM group and 15.7 ± 16.0 months in the NSM group. The ND-NSM group had a higher rate of total complications by breast than the NSM group although not statistically significant (29% versus 20%; P = 0.175). ND-NSM breasts and NSM breasts did not differ statistically in rates of major and minor complications of hematomas (major 2.3% versus 0.3%, minor 0.0% versus 0.3%; P = 0.094), seromas (major 2.4% versus 0.3%, minor 4.8% versus 2.0%; P = 0.137), or skin necrosis (major 9.5% versus 5.6%, minor 0.0% versus 4.3%; P = 0.256) (Table 4).
Table 4.
Complications
| ND + NSM | NSM | P | ||||
|---|---|---|---|---|---|---|
| Parameter | Patients (n = 22) | Breasts (n = 42) | Patients (n = 175) | Breasts (n = 302) | By Patient | By Breast |
| Any complication, n (%) | 11 (50.0) | 12 (28.6) | 57 (32.6) | 59 (19.5) | 0.105 | 0.175 |
| Major complication | 7 (31.8) | 8 (19.0) | 29 (16.6) | 30 (10.0) | 0.081 | 0.078 |
| Minor Complication | 5 (22.7) | 5 (11.9) | 35 (20.0) | 35 (11.6) | 0.764 | 0.952 |
| Any NAC complication, n (%) | 4 (18.1) | 5 (11.9) | 27 (15.4) | 28 (9.3) | 0.771 | 0.510 |
| Epidermolysis, n (%) | 3 (13.6) | 3 (7.1) | 16 (9.1) | 16 (5.3) | ||
| Partial necrosis | 1 (4.5) | 2 (4.8) | 6 (3.4) | 6 (2.0) | ||
| Total necrosis | 0 (0) | 0 (0) | 5 (2.9) | 6 (2.0) | ||
| Skin necrosis, n (%) | ||||||
| Major | 3 (13.6) | 4 (9.5) | 17 (9.7) | 17 (5.6) | 0.375 | 0.256 |
| Minor | 0 (0) | 0 (0) | 13 (7.4) | 13 (4.3) | ||
| Infection, n (%) | 3 (13.6) | 3 (7.1) | 15 (8.6) | 15 (5.0) | 0.437 | 0.553 |
| Implant loss*, n (%) | 0 (0) | 0 (0) | 21 (13.3) | 21 (7.6) | 0.086 | 0.078 |
| Seroma, n (%) | ||||||
| Major | 1 (4.5) | 1 (2.4) | 1 (0.6) | 1 (0.3) | 0.092 | 0.137 |
| Minor | 2 (9.1) | 2 (4.8) | 6 (3.4) | 6 (2.0) | ||
| Hematoma, n (%) | 0.094 | 0.077 | 0.094 | |||
| Major | 1 (4.5) | 1 (2.3) | 1 (0.6) | 1 (0.3) | ||
| Minor | 0 (0) | 0 (0) | 1 (0.6) | 1 (0.3) | ||
n = 158 patients, 278 breasts.
The ND-NSM and NSM groups had similar rates of total NAC loss (0% versus 2%), partial NAC loss (5% versus 2%), and NAC epidermolysis (7% versus 5%) (P = 0.510). Out of the patients who received implant reconstruction, no ND-NSM patients experienced implant loss, whereas 13% NSM patients experienced implant loss, although not statistically significant (P = 0.086). ND-NSM patients had higher rates of infections than NSM-only patients though not statistically significant (14% versus 9%; P = 0.437) (Table 4).
DISCUSSION
NSM provides women requiring mastectomies an optimal reconstructive option that preserves the NAC, playing a large role in patient satisfaction, as well as psychosocial and sexual well-being.2,13 The NSM procedure, however, has been associated with NAC necrosis rates from 6% to 30%,3–5 likely due to compromised NAC blood supply and retraction trauma.14 Higher rates of necrosis have been associated with patient risk factors, including smoking, diabetes, large ptotic breasts, and prior radiation.7 Additionally, some breast morphologies, such as ptotic or hypertrophic breasts, do not lend themselves well to NSM due to suboptimal skin envelope dimensions and NAC position.12 There are published studies that demonstrate the direct correlation between breast volume and NAC or skin necrosis. NAC necrosis has been demonstrated to be as high as 35% in breasts more than 400 grams compared to 4% in breasts less than 400 grams.15
Attempts to improve the NSM candidacy of these types of patients are well published.11 Spear et al12 described a two-stage mammoplasty followed by NSM to convert patients with grade 2 or 3 ptosis to more optimal NSM candidates. They found a partial NAC necrosis rate of 13.9% and a mastectomy flap necrosis rate of 16.3%. While the Spear experience described an improved rate of necrosis compared to historical rates of NSM alone, further outcome improvements are necessary for NSMs.
Delay procedures have been implemented since the 16th century, when Tagliacozzi used the principle to improve tissue flap survival.16 Its mechanism involves inducing “ischemic preconditioning” with subsequent angiogenesis, vasculogenesis, and dilatation of choke vessels, allowing improved blood supply to the flap before its transfer.17,18 A commonly used delay in breast reconstruction is associated with the pedicled TRAM flap, in which strategic ligation of superficial and deep inferior epigastric vessels before flap transfer improves harvestable flap volume.19,20 This method has resulted in fewer ischemic flap complications in breast reconstruction patients with high-risk factors, including obesity, smoking, and prior radiation.21
The intent of ND in NSM is to reduce ischemic complications, particularly in higher risk patients. Use of ND with NSM was first described in 2005 by Palmieri et al,8 reporting partial NAC necrosis in only one of 18 patients (5.5%). Jensen et al5 performed ND and NSM procedures in patients with elevated risk for necrosis such as ptosis, preexisting breast scars, and active smoking, reporting no NAC necrosis. Similarly, Bertoni et al10 showed a low rate of partial NAC necrosis (7.1%) and no complete necrosis using ND before NSM in patients with ptosis, BMI greater than or equal to 30, prior breast surgery, prior radiation, or active smoking.
Our group used an ND technique similar to ones described by Jensen et al5 and Bertoni et al,10 but with a smaller area of skin dissection around the NAC (1 cm) compared to those described (4‐5 cm). We did not use a silicone sheet, unlike Martinez et al,9 as we felt revascularization over 2 weeks from the tissue under the skin was unlikely to hinder the desired delay phenomenon. Our ND-NSM patients had higher rates of ptotic and hypertrophic breast morphologies as evidenced by the significantly greater elevated BMI, grade 2‐3 breast ptosis, mastectomy specimen weights, and previous breast surgery. These characteristics would naturally dispose them to higher rates of complications such as skin necrosis and NAC loss.
Although not statistically significant, the ND-NSM group had higher total and major complication rates than the NSM group, possibly due to small ND-NSM sample size. This potential difference could be explained by the finding that the ND-NSM group had almost twice the percentage of past breast surgery as the NSM group. Many of our ND patients were originally suboptimal candidates for NSM due to breast size and ptosis and underwent preparatory mammoplasty to optimize their breast envelope and NAC position before undergoing NSM, creating scars that could jeopardize NAC viability with NSM. Despite this increased risk, NAC complications in the ND-NSM group remained low (18.1% patients, 11.9% nipples), and similar to the NSM group (15.5% patients, 9.3% nipples). There was no NAC loss in the ND-NSM group compared to the NSM group (2.9% NAC loss). Our study demonstrated that the ND procedure allows higher risk patients to have NSM with a complication profile similar to lower risk patients. It also showed that ND can potentially help expand the pool of candidates for NSM by keeping nipple complications low in patients who undergo preparatory mammoplasty surgery.
A concern with the addition of the ND procedure is delaying definitive treatment and increasing time to mastectomy in patients with breast cancer. In our patients with breast cancer, excluding those receiving neoadjuvant chemotherapy, we reported an average time between NSM decision and NSM of 42.2 ± 18.9 days in ND patients and 37.1 ± 17.0 days in NSM-only patients. The time between ND and NSM averaged 16 days, which is similar to other studies that ranged from 1 to 6 weeks.5,8–10 There was no significant delay of treatment when coordinating care of breast cancer patients with and without ND, although a greater sample size is required in future studies to adequately power this comparison. The eight ND patients who received a preparatory mammoplasty all had prophylactic indications. The average time elapsed from the preparatory surgery to ND was 110 days with a range of 70‐266 days, which is longer than the 3‐4 week minimum time between stages described by Spear et al.12 The preparatory group had no NAC loss and only one major complication of skin necrosis. We agree with Spear in recommending a preparatory mammoplasty in patients with significant breast ptosis or large volume to optimize candidacy for NSM, and we believe ND can improve upon the 13.9% partial NAC necrosis rates described in their study. While the ND procedure adds a surgical procedure to patients’ clinical courses, it is a minor outpatient procedure performed under local anesthetic with sedation that can make NSM available to more women,22 provide valuable retroareolar biopsy information before committing to NSM, and may expand the feasibility of NSM when working with breast surgeons less experienced with the NSM procedure.
Our study is limited to a single center’s experience with a small group of patients receiving ND. This review is also inherently limited by its retrospective design and potentially flawed or incomplete data collected from patient charts. Finally, the ND-NSM group had a shorter follow-up period than the NSM-only group, which may have limited potential complications captured within this follow-up time frame. Despite these weaknesses, we feel that our outcomes support the use of a staged approach employing the ND procedure for certain patients undergoing NSM.
CONCLUSIONS
While NSM can provide exceptional aesthetic outcomes for mastectomy patients, not all patients are good candidates for this procedure. ND as well as preparatory mammoplasty to improve the breast envelope and NAC position may allow more women to undergo NSM while protecting the viability of the NAC.
ACKNOWLEDGMENTS
The authors would like to thank Xiao Zhu, MD, for illustrations of the surgical techniques.
Footnotes
Presented virtually at the Northeastern Society of Plastic Surgeon Virtual 2020 Meeting, September 26, 2020, at the 65th Annual Scientific Meeting of the Robert H. Ivy Society of Plastic Surgeons, Pittsburgh, Pennsylvania, April 13, 2019, at the 62nd Annual Meeting of the Ohio Valley Society of Plastic Surgeons, French Lick, Indiana, June 2, 2019, at the UPMC Plastic Surgery Resident Research Day, Pittsburgh, Pennsylvania, June 21, 2018, and as poster at the Richard L. Simmons Lecture in Surgical Science and Department of Surgery Research Day, Pittsburgh, Pennsylvania, May 8, 2019.
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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