Abstract
Background
The safety and practicality of nipple-sparing mastectomy (NSM) are controversial.
Methods
Review of a large breast center’s experience identified 99 women who underwent intended NSM with subareolar biopsy and breast reconstruction for primary breast cancer. Outcome was assessed by biopsy status, postoperative nipple necrosis or removal, cancer recurrence, and cancer-specific death.
Results
NSM was attempted for invasive cancer (64 breasts, 24 with positive lymph nodes), noninvasive cancer (35 breasts), and/or contralateral prophylaxis (50 breasts). Twenty-two nipples (14%) were removed because of positive subareolar biopsy results (frozen or permanent section). Seven patients underwent a pre-NSM surgical delay procedure because of increased risk for nipple necrosis. Reconstruction used transverse rectus abdominis myocutaneous flaps (56 breasts), latissimus flaps with expander (35 breasts), or expander alone (58 breasts). Of 127 retained nipples, 8 (6%) became necrotic and 2 others (2%) were removed at patient request. There was no nipple necrosis when NSM was performed after a surgical delay procedure. At a mean follow-up of 60.2 months, all 3 patients with recurrence had biopsy-proven subareolar disease and had undergone nipple removal at original mastectomy. There were no deaths.
Conclusions
Five-year recurrence rate is low when NSM margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high-risk patients. NSM can be performed safely with all types of breast reconstruction.
Similar content being viewed by others
References
Freeman BS. Subcutaneous mastectomy for benign breast lesions with immediate or delayed prosthetic replacement. Plast Reconstr Surg. 1962;30:676–82.
Hinton CP, Doyle PJ, Blamey RW, et al. Subcutaneous mastectomy for primary operable breast cancer. Br J Surg. 1984;71:469–72.
Simmons RM, Brennan M, Christos P, King V, Osborne M. Analysis of nipple/areolar involvement with mastectomy: can the areola be preserved? Ann Surg Oncol. 2002;9:165–8.
Cense HA, Rutgers EJ, Lopes Cardozo M, Van Lanschot JJ. Nipple-sparing mastectomy in breast cancer: a viable option? Eur J Surg Oncol. 2001;27:521–6.
Crile G Jr, Esselstyn CB Jr, Hermann RE, Hoerr SO. Partial mastectomy for carcinoma of the breast. Surg Gynecol Obstet. 1973:136:929–32.
Veronesi U, Cascinelli N, Mariaani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347:1227–32.
Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–41.
Jensen JA. When can the nipple-areolar complex safely be spared during mastectomy? Plast Reconstr Surg. 2002;109:805–7.
Jensen JA. Breast cancer: is nipple-sparing mastectomy safe? Ann Surg. 2009;250:657.
Palmieri B, Baitchev G, Grappolini S, Costa A, Benuzzi G. Delayed nipple-sparing modified subcutaneous mastectomy: rationale and technique. Breast J. 2005;11:173–8.
Gerber B, Krause A, Reimer T, et al. Skin-sparing mastectomy with conservation of the nipple-areolar complex and autologous reconstruction is an oncologically safe procedure. Ann Surg. 2003;238:120–7.
Gerber B, Krause A, Dieterich M, Reimer T, Kundt G. The oncological safety of skin sparing mastectomy with conservation of the nipple-areolar complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249:461–8.
Petit JY, Veronesi U, Orecchia R, et al. Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment. Breast Cancer Res Treat. 2006;96:47–51.
Crowe JP Jr, Kim JA, Yetman R, et al. Nipple-sparing mastectomy: technique and results of 54 procedures. Arch Surg. 2004;139:148–50.
Crowe JP Jr, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143:1106–10.
Margulies AG, Hochberg J, Kepple J, et al. Total skin-sparing mastectomy without preservation of the nipple-areolar complex. Am J Surg. 2005;190:907–12.
Sacchini V, Pinotti JA, Barros A, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203:704–14.
Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34:143–8.
Rusby JE, Kirstein LJ, Brachtel EF, et al. Nipple-sparing mastectomy: lessons from ex vivo procedures. Breast J. 2008;14:464–70.
Caruso F, Ferrara M, Castiglione G, et al. Nipple sparing subcutaneous mastectomy: sixty-six months follow-up. Eur J Surg Oncol. 2006;32:937–40.
Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949–55.
Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353(9165):1641–8.
Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med. 1999;340:77–84.
Goodnight JE Jr, Quagliana JM, Morton DL. Failure of subcutaneous mastectomy to prevent the development of breast cancer. J Surg Oncol. 1984;26:198–201.
Goldman LD, Goldwyn RM. Some anatomical considerations of subcutaneous mastectomy. Plast Reconstr Surg. 1973;51:501–5.
Hartmann LC, Sellers TA, Schaid DJ, et al. Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers. J Natl Cancer Inst. 2001;93:1633–7.
Spear SL, Hannan CM, Willey SC, Cocilovo C. Nipple-sparing mastectomy. Plast Reconstr Surg. 2009;123:1665–73.
Jensen JA. Nipple-sparing mastectomy: what is the best evidence for safety? Plast Reconstr Surg. 2009;124:2195–7.
Acknowledgment
Supported by funding from the Avon Foundation, Margie and Robert E. Petersen Foundation (Los Angeles, CA), QVC and the Fashion Footwear Association of New York Charitable Foundation (New York, NY), Mrs. Lois Rosen (Los Angeles, CA), the Associates for Breast and Prostate Cancer Studies (Santa Monica, CA), Maria Lucia and Fernando Diez Barroso (Beverly Hills, CA), Randa and Ghassan Ghandour (Athens, Greece), and the John Wayne Cancer Institute Auxiliary.
Conflict of interest
The authors declare no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jensen, J.A., Orringer, J.S. & Giuliano, A.E. Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years. Ann Surg Oncol 18, 1665–1670 (2011). https://doi.org/10.1245/s10434-010-1475-4
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-010-1475-4