Nipple-sparing mastectomy provides new option for autologous breast reconstruction

Study reports good results in selected patients with reconstruction using patient's own tissues

January 29, 2013
American Society of Plastic Surgeons (ASPS)

For some women who undergo a mastectomy, surgeons can use a "nipple-sparing" technique to achieve a more natural-looking reconstruction using the patient's own tissues, according to a report in the February issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Although a technically challenging procedure that requires careful planning, nipple-sparing mastectomy with autologous breast reconstruction provides good results in appropriately selected patients, according to the report by ASPS Member Surgeon Dr. Jamie Levine of the Institute of Reconstructive Plastic Surgery, New York University.

Reconstruction after nipple-sparing mastectomy

"Nipple-sparing" procedures are an increasingly popular option for women undergoing a mastectomy. In these procedures, the surgeon carefully designs the operation so as to preserve the nipple-areola complex (NAC) for use in immediate breast reconstruction. In addition to the cosmetic advantages, reconstruction using the preserved NAC can lead to increased satisfaction for women undergoing mastectomy.

Dr. Levine and colleagues reported on their experience with the use of autologous reconstruction (using the patient's own tissues) after nipple-sparing mastectomy. They performed a total of 85 breast "free flap" reconstructions performed in 51 women between 2007 and 2011.

About two-thirds of the women had preventive mastectomies. Most of these patients had mutations that placed them at high genetic risk for breast cancer. The remaining women underwent nipple-sparing mastectomy after initial examination suggested there was no cancer involving the NAC area.

Most of the reconstructions were done using "donor" flaps from the abdomen. The reconstructions employed "the full gamut" of microsurgical breast reconstruction techniques tailored to the individual patient's situation.

Good results achieved with careful selection and planning

The results were good with relatively low complication rates. The most common complication was tissue death (necrosis) of part of the donor flap used for reconstruction, occurring in about 13% of patients. These complications were managed without losing the tissue flap used for reconstruction.

However, several women developed complete necrosis of the nipple area, resulting in loss of the NAC. This complication appeared more common in women with a history of smoking. In two women, there was evidence of cancer involvement under the NAC, which made it impossible to preserve the nipple.

Many of the women later underwent additional surgery, either on the reconstructed breast or at the donor site. In some cases, fat grafting was used to augment the breasts after reconstruction.

Nipple-sparing mastectomy is an increasingly popular option, especially for women undergoing preventive mastectomy. Most previous reports of this technique have focused on women undergoing breast reconstruction using implants. The new report is the largest reported experience to date with autologous breast reconstruction after nipple-sparing mastectomy. "Ensuring optimal outcomes, including risk reduction and NAC preservation, requires vigilant preoperative evaluation and attentive execution," Dr. Levine and coauthors wrote.

They emphasize that the number of nipple-sparing mastectomy procedures is increasing, but it is still a relatively new and technically challenging procedure. It is only appropriate in carefully selected cases, with close cooperation and communication between patients and her surgeons. Within the study limitations, Dr. Levine and colleagues believe their findings "positively contribute to the growing body of literature surrounding reconstruction following nipple-sparing mastectomy."