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General Surgery

Nipple – Sparing Mastectomy

Nipple-sparing mastectomy (NSM) is a surgery that removes the breast tissue, but preserves the skin and nipple areola complex (NAC; nipple and areola). By retaining the natural parts of the breast, the procedure provides superior cosmetic and psychological benefit for the patient. However, the surgery may provide enhanced aesthetic outcomes at the expense of its oncological safety, and may be associated with cancer recurrence.

Many believe that the chance of residual cancer tissue at the base of the NAC is a major drawback when the nipple is spared. Studies to evaluate this risk have shown varied results. Many backward-looking studies have noticed low but long-term occurrence of cancer in the nipple-areola complex after nipple-sparing mastectomy.

However, others have demonstrated that the risk of cancer recurrence is low and the involvement of the nipple is very rare. If it does get infected, it can be removed surgically. A 2011 research studied more than 150 NSM surgeries across 21 years and found neither primary cancer nor recurrence following NSM. Many US studies have also confirmed that NAC can be performed with low rates of complications and recurrence. With this, the procedure is slowly entering the mainstream prevention and treatment modalities for breast cancer. It is being considered over skin-sparing mastectomy (in which the NAC is removed) in view of a better body image and higher patient satisfaction. The general occurrence of BRCA mutations in younger women has boosted its popularity even more.

However, it has been suggested that the procedure may not be appropriate for everyone and a careful selection based on the anatomy and breast pathology will play an important part in determining its success. Success can be achieved in those who are nonsmokers, not obese, and without pendulous breasts. The involvement of NAC was seen to be greater in the following cases:

  • Larger tumor size
  • Central location
  • Shorter distance between tumor and nipple
  • Lymphovascular involvement
  • Metastases of lymph node
  • Younger age
  • Advanced cancer stage and grade
  • Extensive in situ component

A 2011 study (Billar et al, Ann Surg Oncol) concluded that clinical and imaging abnormalities at the NAC were sufficient to predict disease. The decision to spare the nipple is usually taken after analyzing the tissue below the areola.

Apart from providing aesthetic value and improving quality of life, the surgeon should strive to lower the chances of the cancer from coming back. An inverted sock technique of carefully and thoroughly clearing the underlying skin of the nipple and areola helps minimize recurrence.

Conclusion

Under the name of subcutaneous mastectomy, NSM was initially known for breast cancer prevention, fibrocystic disease, but not so much for cancer. Reports of primary cancer or recurrence in the residual tissue in the 1980s led to surgeons abandoning this technique until the past few years when it regained its popularity. Surgical problems, like the difficulty in removing the entire breast through a limited opening, increased complications of wound formation and tissue death, have discouraged the practice. The current nipple-sparing mastectomy surgery involves a more radical removal of the breast when compared to the subcutaneous mastectomy.

However, if the procedure fails to optimize or enhance the overall cosmetic outcome, it may not hold greater advantage over skin sparing mastectomy, which is simpler and associated with lower complications. In addition, with the high potential for improved cosmetic value, the nipple-sparing mastectomy will be worthwhile for the patient if the benefits override the probable chances of oncologic risk even if it is low.