One of the more notable surgical advances in breast cancer treatment and prevention is nipple sparing mastectomy. This is a surgical technique similar to the traditional mastectomy that removes the whole breast, but unique in that it spares the skin, nipple and areola. This is then followed by immediate reconstruction.
While our goal in breast cancer treatment is limited surgery and breast preservation, at least 25% of patients will still require, or desire, mastectomy. By preserving the nipple, the psychological burden of mastectomy is greatly reduced. The nipple is central to the concept of breast preservation, and in properly selected patients, nipple-sparing mastectomy can provide the best treatment and cosmesis.
Who is a candidate?
There are two main issues governing the selection of candidates for nipple-sparing mastectomy:
1. oncologic safety (will this safely treat cancer without leaving any behind?); and
2. cosmesis (will this enhance the appearance of the reconstructed breast?).
Patients who have large cancers that are close to the nipple run the risk of leaving behind cancer cells in the nipple. These patients are not good candidates for this procedure. The surgeon can almost always tell if this is a risk before surgery with imaging studies such as mammogram or MRI. In addition, the surgeon will also check the tissue underneath the nipple for cancer at the time of surgery with a “frozen section.” If there are cancer cells present, then the nipple will need to be removed.
Nipple preservation may not be ideal in patients who have large, pendulous breasts (D-cup or greater). In these patients, the cosmetic effect of nipple preservation is less than optimal. Consultation with a plastic surgeon prior to surgery is necessary to discuss alternative options for reconstruction, which may include areola-tattooing and nipple reconstruction.
Patients without cancer but who have very high cancer risk (gene mutation carriers or multiple family members with breast or ovarian cancer) and want prophylactic mastectomies are often candidates for nipple-sparing mastectomy. Consultation with a both a dedicated breast surgical oncologist and plastic surgeon can help determine this.
What are possible complications?
There are two possible issues that can arise specifically with nipple-sparing mastectomy. In some cases, the blood supply to the nipple is compromised during surgery and the nipple can die. This occurs in less than 10% of properly selected patients, however is more common in patients who smoke, have diabetes or who have prior incisions or previous radiation to the breast. This can sometimes be prevented in patients with these risk by a “nipple-delay” procedure.
The other possible risk is that cancer might be found in the breast close to the nipple after surgery. Rarely, the frozen section of the tissue underneath the nipple may be thought to be cancer-free at the time of surgery, but found to have cancer after additional tests are performed. In some instances, the nipple may need to be removed or radiated.
Is the risk of cancer occurrence or recurrence higher than with skin-sparing or total mastectomy?
The nipple was not traditionally preserved in mastectomy since there are ducts, or breast tissue, within the nipple that are capable of developing breast cancer. Several retrospective studies have shown that the risk of developing cancer within the nipple after nipple sparing mastectomy in properly selected patients is very low to zero. Since nipple-sparing mastectomy is a relatively new surgical technique, 20- and 30-year follow-up data is not yet available. Patients who undergo this procedure, just as with traditional mastectomy, should be carefully followed by their breast surgeon on a regular basis.