​Nipple-sparing Mastectomy: Choosing the Right Breast Surgeon & Getting the Best Reconstruction Outcome by Dr. Constance Chen

Achieving the ideal breast reconstruction depends on the quality of the mastectomy. A nipple-sparing mastectomy, in which the breast skin and the nipple-areola complex are preserved, sets up a patient for the best possible breast reconstruction. With a nipple-sparing mastectomy, the skin of the natural breast is carefully kept intact, and it is the responsibility of the plastic surgeon to fill the natural breast skin with either an implant or natural tissue to create a breast shape. The key to creating a beautiful breast after mastectomy is choosing the right team of breast surgeon and plastic surgeon.

Many breast surgeons have only been trained to perform traditional mastectomies, which involves removing the nipple-areola complex with the surrounding skin in an elliptical excision, creating a horizontal scar across the chest. The result permanently deforms and flattens the three-dimensional shape of the breast.

Nipple-sparing surgery calls for preservation of the nipple-areola complex as part of the breast skin, provided that the nipple-areola complex are not involved in the malignancy, yet it removes all of the remaining breast tissue within the skin. As long as it is oncologically safe, more women should undergo nipple-sparing mastectomies, but an eligible patient may be told she is not a candidate for nipple-sparing surgery if her breast surgeon does not feel comfortable performing the procedure.

For many patients, having bare breasts that look and feel as normal as possible helps them move on from and feel less trapped by their breast cancer diagnosis. For many women, it is not enough to reapproximate a breast mound that suggests a breast shape under clothes. When a woman looks in a mirror, it is helpful to see an ordinary breast with a nipple. For many people, looking normal after a mastectomy can provide a greater sense of control.

Numerous studies looking at nipple-sparing mastectomy in carefully selected patients have shown no statistically significant increase in recurrence when compared to traditional mastectomies. A systematic review of over 12,358 nipple-sparing procedures over 45 years published in the 2016 Archives of Plastic Surgery demonstrated that nipple-sparing mastectomy is oncologically safe when tumors smaller than 5 cm are peripherally located more than 2 cm from the nipple. More recently, a study published in the 2019 Breast Journal found that invasive cancers less than 2 cm from the nipple were oncologically safe to undergo nipple-sparing mastectomy. One reason for this may be that ductal and lobular carcinomas arise from the terminal duct lobular unit (TDLU), which is scarce in the nipple. Studies of the nipple show that the TDLU rarely reaches the base of the nipple, and never reaches the tip of the nipple.

Mastectomies have evolved since the first radical mastectomy was described by William Halsted in 1894. The original Halstedian mastectomy removed the breast, almost all of the breast skin, pectoralis major and minor muscles, and the axillary lymph nodes. Although the Halstedian mastectomy was extremely deforming to the patient, it was believed to be the only way to save the life of the breast cancer patient. In the 1950s, surgeons experimented with “extended radical” or “super-radical” mastectomies, but found no increase in survival. In the 1970s, surgeons realized that a “modified radical mastectomy” that left more of the breast skin and all of the pectoralis muscles intact did not lower survival rates, and the Halstedian mastectomy was largely abandoned.

In the 1990s, sentinel node biopsy, while initially controversial, was shown to offer equal survival to complete axillary node dissection in the appropriate patients while sparing women the sequelae of post-mastectomy lymphedema, and the sentinel node biopsy eventually became standard of care. In the 2000s, more breast surgeons began performing nipple-sparing mastectomies. While a nipple-sparing mastectomy is a more technically difficult operation for the breast surgeon, the oncological safety has now been established in the appropriate patients.

Breast surgeons who do not perform nipple-sparing mastectomies are not setting up their patients for the best result if they undergo breast reconstruction. Nipple-sparing mastectomy is a technically difficult operation, because the exposure to the breast tissue is trickier than with a standard mastectomy that leaves a horizontal scar, but it is worth it for a woman who will be living with the sequelae for the rest of her life. 

For this reason, women who are candidates for nipple-sparing mastectomy should seek out a breast surgeon with the technical skills to provide her with the best possible mastectomy. If her surgeon states that she is not a candidate, she should ask how many nipple-sparing mastectomies the surgeon has performed. Women should not be afraid to keep looking until they find a breast surgeon who is technically capable of performing nipple-sparing mastectomies.

Women who want to optimize the ultimate appearance and shape of their breasts after mastectomy and breast reconstruction must take control of their bodies and do their homework in advance of undergoing the treatment process. The simple decision of what incision a surgeon uses to perform a mastectomy can forever affect the final outcome of a woman’s post-mastectomy breast reconstruction.

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