Annals of Surgical Oncology

, Volume 26, Issue 10, pp 3115–3123 | Cite as

Outcomes of > 1300 Nipple-Sparing Mastectomies with Immediate Reconstruction: The Impact of Expanding Indications on Complications

  • Whitney A. Young
  • Amy C. Degnim
  • Tanya L. Hoskin
  • James W. Jakub
  • Minh-Doan Nguyen
  • Nho V. Tran
  • Christin A. Harless
  • Oscar J. Manrique
  • Judy C. Boughey
  • Tina J. HiekenEmail author
Breast Onology



The enhanced esthetics and demonstrated oncologic safety of nipple-sparing mastectomy (NSM) in selected patients have resulted in increased rates among patients with locally advanced breast cancer and/or additional risk factors (obesity, prior radiation, surgery). Limited data exist on complication and reconstruction success rates in a contemporary patient cohort with expanded indications for NSM.


With institutional review board (IRB) approval, patients treated from 2009 to 2017 with NSM were identified from our prospective breast surgery registry. Main outcomes were 30-day complications requiring treatment and 1-year reconstruction failure rates. Risk factors were assessed using logistic regression.


We evaluated 1301 breasts in 769 women undergoing NSM for cancer (n = 555) or risk reduction (n = 746) with median age of 48 (range 21–77) years. The overall 30-day complication rate was 7.5% (97/1301 breasts) and declined from 14.8% in 2009 to 6.3% in 2017 (p < 0.001), while the proportion of patients with obesity (p = 0.007) and treated with neoadjuvant chemotherapy (p < 0.001) increased. Prior radiation [odds ratio (OR) 2.35, p = 0.04], recent/current smoking (OR 3.37, p < 0.001), and body mass index (BMI) (OR 1.28 per 5-kg/m2 increase, p = 0.03) significantly increased 30-day complication rates. Reconstruction success at 1 year was 96.7%. Prior radiation (OR 5.65, p < 0.001), axillary surgery (OR 2.55, p = 0.006), and postoperative adjuvant radiation (OR 3.22, p = 0.007) significantly affected 1-year reconstruction failure.


The 30-day complication rates of NSM decreased, despite broadened indications among higher-risk patients over time. These data confirm a team learning curve with NSM and also demonstrate that the nipple-sparing approach is suitable for appropriately selected higher-risk patients for both risk reduction and cancer treatment.



Dr. Hieken has unrelated research support from Genentech; the other authors report no relevant financial disclosures.


  1. 1.
    Wang F, Peled AW, Garwood E, et al. Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes. Ann Surg Oncol. 2014;21:3223–30.CrossRefGoogle Scholar
  2. 2.
    Krajewski AC, Boughey JC, Degnim AC, et al. Expanded indications and improved outcomes for nipple-sparing mastectomy over time. Ann Surg Oncol. 2015;22:3317–23.CrossRefGoogle Scholar
  3. 3.
    Sisco M, Kyrillos AM, Lapin BR, Wang CE, Yao KA. Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States. Breast Cancer Res Treat. 2016;160:111–20.CrossRefGoogle Scholar
  4. 4.
    Freeman MD, Gopman JM, Salzberg CA. The evolution of mastectomy surgical technique: from mutilation to medicine. Gland Surg. 2018;7:308–15.CrossRefGoogle Scholar
  5. 5.
    Yugueros P BU. Current concepts and techniques in subcutaneous mastectomy. Oper Tech Gen Surg. 2000;2:110–7.CrossRefGoogle Scholar
  6. 6.
    Hieken TJ, Boolbol SK, Dietz JR. Nipple-sparing mastectomy: indications, contraindications, risks, benefits, and techniques. Ann Surg Oncol. 2016;23:3138–44.CrossRefGoogle Scholar
  7. 7.
    de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol. 2011;18:3117–22.CrossRefGoogle Scholar
  8. 8.
    NCCN Clinical Practice Guidelines: Breast Cancer Version 2.2016. 2016. Accessed 10 Apr 2016.Google Scholar
  9. 9.
    Vlajcic Z, Zic R, Stanec S, Stanec Z. Areola-sparing mastectomy with immediate breast reconstruction. Ann Plast Surg. 2005;54:581.CrossRefGoogle Scholar
  10. 10.
    Brachtel EF, Rusby JE, Michaelson JS, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27:4948–54.CrossRefGoogle Scholar
  11. 11.
    Steen ST, Chung AP, Han SH, Vinstein AL, Yoon JL, Giuliano AE. Predicting nipple–areolar involvement using preoperative breast MRI and primary tumor characteristics. Ann Surg Oncol. 2013;20:633–9.CrossRefGoogle Scholar
  12. 12.
    Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg. 2010;97:305–16.CrossRefGoogle Scholar
  13. 13.
    Billar JA, Dueck AC, Gray RJ, Wasif N, Pockaj BA. Preoperative predictors of nipple–areola complex involvement for patients undergoing mastectomy for breast cancer. Ann Surg Oncol. 2011;18:3123–8.CrossRefGoogle Scholar
  14. 14.
    Fortunato L, Loreti A, Andrich R, et al. When mastectomy is needed: is the nipple-sparing procedure a new standard with very few contraindications? J Surg Oncol. 2013;108:207–12.CrossRefGoogle Scholar
  15. 15.
    Warren Peled A, Foster RD, Stover AC, et al. Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol. 2012;19:3402–9.CrossRefGoogle Scholar
  16. 16.
    Smith BL, Tang R, Rai U, et al. Oncologic safety of nipple-sparing mastectomy in women with breast cancer. J Am Coll Surg. 2017;225:361–5.CrossRefGoogle Scholar
  17. 17.
    Murphy BL, Hoskin TL, Boughey JC, et al. Outcomes and feasibility of nipple-sparing mastectomy for node-positive breast cancer Patients. Am J Surg. 2017;213:810–3.CrossRefGoogle Scholar
  18. 18.
    Murphy BL, Boughey JC, Hieken TJ. Nipple-sparing mastectomy for the management of recurrent breast cancer. Clin Breast Cancer. 2017;17:e209–13.CrossRefGoogle Scholar
  19. 19.
    Frederick MJ, Lin AM, Neuman R, Smith BL, Austen WG, Jr., Colwell AS. Nipple-sparing mastectomy in patients with previous breast surgery: comparative analysis of 775 immediate breast reconstructions. Plast Reconstr Surg. 2015;135:954e–62e.CrossRefGoogle Scholar
  20. 20.
    Corso G, De Lorenzi F, Vicini E, et al. Nipple-sparing mastectomy with different approaches: surgical incisions, complications, and cosmetic results. Preliminary results of 100 consecutive patients at a single center. J Plast Reconstr Aesthet Surg. 2018;71:1751–60.CrossRefGoogle Scholar
  21. 21.
    Lee CH, Cheng MH, Wu CW, Kuo WL, Yu CC, Huang JJ. Nipple-sparing mastectomy and immediate breast reconstruction after recurrence from previous breast conservation therapy. Ann Plast Surg. 2019;82:S95–102.CrossRefGoogle Scholar
  22. 22.
    NCCN Clinical Practice Guidelines: Breast Cancer v1.2019 physician_gls/pdf/breast_risk.pdf 2016. 2019. Accessed Mar 1 2019.
  23. 23.
    Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20:3218–22.CrossRefGoogle Scholar
  24. 24.
    Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg. 2013;132:1043–54.CrossRefGoogle Scholar
  25. 25.
    Tang R, Coopey SB, Colwell AS, et al. Nipple-sparing mastectomy in irradiated breasts: selecting patients to minimize complications. Ann Surg Oncol. 2015;22:3331–7.CrossRefGoogle Scholar
  26. 26.
    Dull B, Conant L, Myckatyn T, Tenenbaum M, Cyr A, Margenthaler JA. Nipple-sparing mastectomies: clinical outcomes from a single academic institution. Mol Clin Oncol. 2017;6:737–42.CrossRefGoogle Scholar
  27. 27.
    Heidemann LN, Gunnarsson GL, Salzberg CA, Sorensen JA, Thomsen JB. Complications following nipple-sparing mastectomy and immediate acellular dermal matrix implant-based breast reconstruction-a systematic review and meta-analysis. Plast Reconstr Surg Glob Open. 2018;6:e1625.CrossRefGoogle Scholar
  28. 28.
    Donovan CA, Harit AP, Chung A, Bao J, Giuliano AE, Amersi F. Oncological and surgical outcomes after nipple-sparing mastectomy: do incisions matter? Ann Surg Oncol. 2016;23:3226–31.CrossRefGoogle Scholar
  29. 29.
    Frey JD, Choi M, Salibian AA, Karp NS. Comparison of outcomes with tissue expander, immediate implant, and autologous breast reconstruction in greater than 1000 nipple-sparing mastectomies. Plast Reconstr Surg. 2017;139:1300–10.CrossRefGoogle Scholar
  30. 30.
    Mitchell SD, Willey SC, Beitsch P, Feldman S. Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry. Gland Surg. 2018;7:247–57.CrossRefGoogle Scholar
  31. 31.
    De Vita R, Zoccali G, Buccheri EM, Costantini M, Botti C, Pozzi M. Outcome evaluation after 2023 nipple-sparing mastectomies: our experience. Plast Reconstr Surg. 2017;139:335e–47e.CrossRefGoogle Scholar
  32. 32.
    Galimberti V, Morigi C, Bagnardi V, et al. Oncological outcomes of nipple-sparing mastectomy: a single-center experience of 1989 patients. Ann Surg Oncol. 2018;25:3849–57.CrossRefGoogle Scholar
  33. 33.
    Petit JY, Veronesi U, Lohsiriwat V, et al. Nipple-sparing mastectomy—is it worth the risk? Nat Rev Clin Oncol. 2011;8:742–7.CrossRefGoogle Scholar
  34. 34.
    Peled AW, Sears M, Wang F, et al. Complications after total skin-sparing mastectomy and expander-implant reconstruction: effects of radiation therapy on the stages of reconstruction. Ann Plast Surg. 2018;80:10–3.Google Scholar
  35. 35.
    Kronowitz SJ. Current status of autologous tissue-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg. 2012;130:282–92.CrossRefGoogle Scholar
  36. 36.
    Fowble B, Park C, Wang F, et al. Rates of reconstruction failure in patients undergoing immediate reconstruction with tissue expanders and/or implants and postmastectomy radiation therapy. Int J Radiat Oncol Biol Phys. 2015;92:634–41.CrossRefGoogle Scholar
  37. 37.
    Kronowitz SJ, Lam C, Terefe W, et al. A multidisciplinary protocol for planned skin-preserving delayed breast reconstruction for patients with locally advanced breast cancer requiring postmastectomy radiation therapy: 3-year follow-up. Plast Reconstr Surg. 2011;127:2154–66.CrossRefGoogle Scholar
  38. 38.
    Piper M, Peled AW, Foster RD, Moore DH, Esserman LJ. Total skin-sparing mastectomy: a systematic review of oncologic outcomes and postoperative complications. Ann Plast Surg. 2013;70:435–7.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Whitney A. Young
    • 1
  • Amy C. Degnim
    • 1
  • Tanya L. Hoskin
    • 2
  • James W. Jakub
    • 1
  • Minh-Doan Nguyen
    • 1
  • Nho V. Tran
    • 1
  • Christin A. Harless
    • 1
  • Oscar J. Manrique
    • 1
  • Judy C. Boughey
    • 1
  • Tina J. Hieken
    • 1
    Email author
  1. 1.Department of SurgeryMayo ClinicRochesterUSA
  2. 2.Department of Health Sciences ResearchMayo ClinicRochesterUSA

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