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Background:
Nipple sparing mastectomy (NSM) followed by immediate reconstruction is rapidly gaining popularity in patients undergoing mastectomy for either prophylactic or oncologic indications; Still, there remains concern regarding the potential for malignancy in the residual tissue behind the nipple areola complex (NAC). Areola sparing mastectomy (ASM) minimizes oncologic risk by removing breast tissue and lactiferous ducts behind the nipple and eliminates risk of post operative native nipple loss.
Methods:
A retrospective review of 80 consecutive breast reconstructions following NSM and ASM from 2009 to 2012 was conducted. Reconstructions were performed by one of three plastic surgeons from a single group The decision for nipple preservation was based on current oncologic principles. Areola sparing mastectomies were offered if nipple preservation was contraindicated and nipple reconstruction could be provided utilizing flap skin or excess areolar skin. Thirty day complications, need for revision and secondary procedures were recorded. Photographic analysis was performed on 31 patients after completion of reconstructive procedures (9 ASM, 22 NSM). Aesthetic outcomes assessed included NAC aesthetic outcome, scars and overall reconstruction. Paired t-tests were performed between groups using a p-value of 0.01.
Results:
We identified 41 women undergoing NSM or ASM (80 breasts). Follow up ranged between 3-18 months (mean 9 months). Eleven patients (21 breasts) underwent ASM and reconstructions (11 free flaps and 10 prosthetic). Thirty women underwent 59 breast reconstructions after NSM (15 free flaps and 42 prosthetic). There were no complications related to areola skin loss in the ASM group. In the NSM group 2 patients had unilateral partial nipple loss (3.3%) and 3 patients had unilateral temporary areola skin slough (5%). One patient in this group had 40% areola loss (1.7%). After ASM with free flap reconstruction 8 nipples were reconstructed at initial operation. The remainder of reconstructions had delayed nipple creation. One patient developed bilateral partial skin loss following nipple creation. In comparing ASM to NSM ,the average aesthetic score for final NAC aesthetic outcome and overall reconstruction was slightly higher than with NSM but did not reach statistical significance (p= 0.662, p=0.03) . Significant findings in the subgroup analysis were overall scars in patients with implant reconstructions favoring NSM (p= 0.0007)
Conclusion:
Areola sparing mastectomy has been described previously in the literature but has not been popularized. We have shown this technique allows for a low incidence of complications without significant difference in NAC aesthetic outcome when compared to patients undergoing NSM. Following ASM, nipple reconstruction may be performed using skin from an underlying flap or using the areola skin. In selected patients, this procedure may provide cosmetically superior results by providing a more robust reconstructed nipple compared to a cored-out preserved nipple, or by reducing areola size in patients with large areolas. While no evaluation of oncologic outcome has been performed in our study group yet, the published risk of malignancy after ASM has been reported as lower than after NSM (<1% vs. 6-7%).