Annals of Surgical Oncology

, Volume 19, Issue 11, pp 3402–3409 | Cite as

Outcomes after Total Skin-sparing Mastectomy and Immediate Reconstruction in 657 Breasts

  • Anne Warren Peled
  • Robert D. Foster
  • Allison C. Stover
  • Kaoru Itakura
  • Cheryl A. Ewing
  • Michael Alvarado
  • E. Shelley Hwang
  • Laura J. Esserman
Breast Oncology



Total skin-sparing mastectomy (TSSM), a technique comprising removal of all breast and nipple tissue while preserving the entire skin envelope, is increasingly offered to women for therapeutic and prophylactic indications. However, standard use of the procedure remains controversial as a result oft concerns regarding oncologic safety and risk of complications.


Outcomes from a prospectively maintained database of patients undergoing TSSM and immediate breast reconstruction from 2001 to 2010 were reviewed. Outcome measures included postoperative complications, tumor involvement of the nipple–areolar complex (NAC) on pathologic analysis, and cancer recurrence.


TSSM was performed on 657 breasts in 428 patients. Indications included in situ cancer [111 breasts (16.9 %)], invasive cancer [301 breasts (45.8 %)], and prophylactic risk-reduction [245 breasts (37.3 %)]. A total of 210 patients (49 %) had neoadjuvant chemotherapy, 78 (18.2 %) had adjuvant chemotherapy, and 114 (26.7 %) had postmastectomy radiotherapy. Nipple tissue contained in situ cancer in 11 breasts (1.7 %) and invasive cancer in 9 breasts (1.4 %); management included repeat excision (7 cases), NAC removal (9 cases), or radiotherapy without further excision (4 cases). Ischemic complications included 13 cases (2 %) of partial nipple loss, 10 cases (1.5 %) of complete nipple loss, and 78 cases (11.9 %) of skin flap necrosis. Overall locoregional recurrence rate was 2 % (median follow-up 28 months), with a 2.4 % rate observed in the subset of patients with at least 3 years’ follow-up (median 45 months). No NAC skin recurrences were observed.


In this large, high-risk cohort, TSSM was associated with low rates of NAC complications, nipple involvement, and locoregional recurrence.


Nipple Postmastectomy Radiotherapy Locoregional Recurrence Rate Periareolar Incision Skin Flap Necrosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors wish to thank Dan Moore, PhD, for his assistance with statistical analysis.


  1. 1.
    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.PubMedCrossRefGoogle Scholar
  2. 2.
    Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol. 2011;18:1665–70.PubMedCrossRefGoogle Scholar
  3. 3.
    Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128:1005–14.PubMedCrossRefGoogle Scholar
  4. 4.
    Sacchini V, Pinotti JA, Barros AC, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203:704–14.PubMedCrossRefGoogle Scholar
  5. 5.
    Komorowski AL, Zanini V, Regolo L, Carolei A, Wysocki WM, Costa A. Necrotic complications after nipple- and areola-sparing mastectomy. World J Surg. 2006;30:1410–3.PubMedCrossRefGoogle Scholar
  6. 6.
    Margulies AG, Hochberg J, Kepple J, Henry-Tillman RS, Westbrook K, Klimber VS. Total skin-sparing mastectomy without preservation of the nipple–areola complex. Am J Surg. 2005;190:907–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ. Optimizing the total skin-sparing mastectomy. Arch Surg. 2008;143:38–45.PubMedCrossRefGoogle Scholar
  8. 8.
    Garwood ER, Moore D, Ewing C, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg. 2009;249:26–32.PubMedCrossRefGoogle Scholar
  9. 9.
    Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212:686–93.PubMedCrossRefGoogle Scholar
  10. 10.
    Southern DA, Faris PD, Brant R, et al. Kaplan-Meier methods yielded misleading results in competing risk scenarios. J Clin Epidemiol. 2006;59:1110–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Paepke S, Schmid R, Fleckner S, et al. Subcutaneous mastectomy with conservation of the nipple–areolar skin. Ann Surg. 2009;250:288–92.PubMedCrossRefGoogle Scholar
  12. 12.
    Kim HJ, Park EH, Lim WS, et al. Nipple–areola skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction is an oncologically safe procedure: a single center study. Ann Surg. 2010;251:493–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Vaughn CJ, Warren Peled A, Esserman LJ, Foster RD. Feasbility of performing total skin-sparing mastectomy in patients with previous periareolar incisions. Presented at: California Society of Plastic Surgeons Annual Meeting, Coronado, CA, 2012.Google Scholar
  14. 14.
    Warren Peled A, Foster RD, Esserman LJ. A comparison of oncoplastic reduction mammoplasty and mastectomy with immediate reconstruction in patients with locally advanced breast cancer. Presented at: Pacific Coast Surgical Association Annual Meeting, Napa, CA, 2012.Google Scholar
  15. 15.
    Rusby JE, Gui GPH. Nipple-sparing mastectomy in women with large or ptotic breasts. J Plast Reconst Aesth Surg. 2010;63:e754–5.CrossRefGoogle Scholar
  16. 16.
    Radovanovic Z, Radovanovic D, Golubovic A, Ivkovic-Kapicl T, Bokorov B, Mandic A. Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures. Scand J Surg. 2010;99:115–8.PubMedGoogle Scholar
  17. 17.
    Forbes JF, Cuzick J, Buzdar A, et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 100-month analysis of the ATAC trial. Lancet Oncol. 2008;9:45–53.PubMedCrossRefGoogle Scholar
  18. 18.
    Early Breast Cancer Trialists’ Collaborative Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of randomised trials. Lancet. 2005;365:1687–17.Google Scholar
  19. 19.
    Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143:1106–10.PubMedCrossRefGoogle Scholar
  20. 20.
    Rusby JE, Brachtel EF, Michaelson JS, et al. Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications. Breast Cancer Res Treat. 2007;106:171–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Warren Peled A, Foster RD, Garwood ER, et al. The effects of acellular dermal matrix in expander-implant breast reconstruction after total skin-sparing mastectomy: results of a prospective practice improvement study. Plast Reconstr Surg. In press.Google Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Anne Warren Peled
    • 1
  • Robert D. Foster
    • 1
  • Allison C. Stover
    • 2
  • Kaoru Itakura
    • 2
  • Cheryl A. Ewing
    • 2
  • Michael Alvarado
    • 2
  • E. Shelley Hwang
    • 3
  • Laura J. Esserman
    • 2
  1. 1.Division of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of CaliforniaSan FranciscoUSA
  2. 2.Department of Surgery, Carol Franc Buck Breast Cancer CenterUniversity of CaliforniaSan FranciscoUSA
  3. 3.Department of SurgeryDuke University Medical CanterDurhamUSA

Personalised recommendations