Nipple Delay May Optimize Nipple Sparing Mastectomy Outcomes
Phoebe L. Lee1, Irene Ma2, M Asher Schusterman II2, Justin Beiriger1, Gretchen Ahrendt3, Marguerite Bonaventura4, Carolyn De La Cruz2, Emilia J. Diego4, Ronald Johnson4, Priscilla F. McAuliffe4, Jennifer G. Steiman4, Michael L. Gimbel2.
1University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, 2University of Pittsburgh Medical Center, Department of Plastic Surgery, Pittsburgh, PA, USA, 3University of Colorado Hospital, Department of Surgery-Surgical Oncology, Aurora, CO, USA, 4University of Pittsburgh Medical Center, Division of Surgical Oncology, Department of Surgery, Pittsburgh, PA, USA.
BackgroundNipple sparing mastectomy (NSM) can provide women with optimal reconstructive aesthetic outcomes. Necrosis of the nipple-areolar complex (NAC) or surrounding skin flaps has been reported in 6- 30% of patients receiving NSM, with higher rates associated with large ptotic breasts, previous breast surgery, previous radiation, and active smoking. The nipple delay (ND) procedure has been shown to improve viability of the NAC in NSM patients with these high-risk factors. We hypothesize that addition of ND to NSM can improve outcomes in patients who are at higher risk for complications following NSM.
MethodsA single institution retrospective review was done of all patients who underwent ND and NSM or NSM alone from 2013 to 2018. Patient demographics, risk factors, and outcomes were collected and compared.
ResultsTwenty-two patients underwent ND prior to NSM (ND-NSM) and 175 patients underwent NSM alone. No statistical difference was found between ND-NSM and NSM in average age (48.6 vs 46.4 years), smoking history (81.8% vs 67.4%), or radiation (13.6% vs 16.5%). The majority of patients who received ND (68.2% vs 28.0%, p=0.000) had a genetic predisposition to breast cancer, while NSM were more likely to carry a breast cancer diagnosis (80.0% vs 45.5%, p=0.000).
The ND-NSM group had significantly more high-risk factors including elevated BMI (26.3 vs 22.9, p=0.000), higher percentage with prior breast surgery (50.0% vs 24.6%, p=0.000), and greater mastectomy specimen weight (646.6 grams vs 303.2 grams, p=0.000). Additionally, ND-NSM were more likely to have undergone preparatory mastopexy or breast reduction prior to NSM (27.3% vs 1.1%, p=0.000).
Most patients underwent a two-stage implant-based reconstruction (69% vs 61.6%). There was no significant difference in the number of days from when patients decided on NSM to when they underwent NSM (42.2 days vs 37.1 days, p=0.483) or in rates of skin necrosis, NAC necrosis, hematoma, seroma, or infection between the groups. However, ND-NSM patients had no total NAC necrosis or implant loss while NSM patients had total NAC loss (5/175, 2.9%) and implant loss (21/175, 13.3%).
DiscussionWhile NSM can provide excellent aesthetic outcomes, not all patients are candidates. We demonstrated in ND-NSM patients no NAC loss in patients with elevated BMI, significant breast ptosis, higher mastectomy specimen weights, and previous breast surgery, without a significant delay of treatment. By using ND, often with preparatory mammoplasty, more women may be NSM candidates while maximally protecting the viability of the NAC.
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