Skip to main content
SpringerLink
Log in

Nipple-Sparing Mastectomy

  • Chapter
  • First Online:
Book cover Changing Paradigms in the Management of Breast Cancer

  • 910 Accesses

Abstract

Nipple-sparing mastectomy (NSM) is now an option for most patients undergoing mastectomy for cancer treatment or risk reduction. Successful NSM requires careful patient selection, proper technique to minimize complications, and meticulous removal of glandular tissue to ensure oncologic safety. NSM is now considered a safe approach for risk reduction and is endorsed by the most recent NCCN guidelines. There are few absolute contraindications to NSM in breast cancer patients; these include direct involvement of the nipple areola complex by tumor on preoperative clinical exam or imaging and the presence of pathological nipple discharge. Locoregional recurrence rates after therapeutic NSM are similar to rates after skin-sparing mastectomies and range from 0 to 4.6% with 10–60 months of follow-up. When NSM patients have been matched to skin-sparing mastectomy patients, no significant difference has been found in 5-year disease-free survival or overall survival rates. The vast majority of studies report no local recurrences within the nipple areola complex. Complication rates for NSM are now acceptably low, with complete nipple necrosis rates of approximately 2%. Proper patient selection can help minimize complications. Patient reported outcomes with NSM for risk reduction and cancer are consistently favorable.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

Abbreviations

NSM:

Nipple-sparing mastectomy

NCCN:

National Comprehensive Cancer Network

cm:

Centimeter

BRCA:

Breast cancer susceptibility gene

NAC:

Nipple areola complex

DIEP:

Deep inferior epigastric perforator

References

  1. Sakorafas GH, Safioleas M. Breast cancer surgery: an historical narrative. Part III. From the sunset of the 19th to the dawn of the 21st century. Eur J Cancer Care. 2010;19:145–66.

    Article  CAS  Google Scholar 

  2. Rice CO, Strickler JH. Adeno-mammectomy for benign breast lesions. Surg Gynecol Obstet. 1951;93(6):759–62.

    CAS  PubMed  Google Scholar 

  3. Rusby JE, Smith BL, Gui GPH. Nipple sparing mastectomy. Br J Surg. 2010;97:305–16.

    Article  CAS  PubMed  Google Scholar 

  4. Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med. 1999;340:77–84.

    Article  CAS  PubMed  Google Scholar 

  5. Kasprzak L, Mesurolle B, Tremblay F, Galvez M, Halwani F, Foulkes WD. Invasive breast cancer following bilateral subcutaneous mastectomy in a BRCA2 mutation carrier: a case report and review of the literature. World J Surg Oncol. 2005;3:52.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048–53.

    Article  CAS  PubMed  Google Scholar 

  7. Yi M, Kronowitz SJ, Meric-Bernstam F, et al. Local, regional, and systemic recurrence rates in patients undergoing skin-sparing mastectomy compared with conventional mastectomy. Cancer. 2011;117:916–24.

    Article  PubMed  Google Scholar 

  8. Smith J, Payne WS, Carney JA. Involvement of the nipple and areola in carcinoma of the breast. Surg Gynecol Obstet. 1976;143:546–8.

    CAS  PubMed  Google Scholar 

  9. Lagios MD, Gates EA, Westdahl PR, Richards V, Alpert BS. A guide to the frequency of nipple involvement in breast cancer. A study of 149 consecutive mastectomies using a serial subgross and correlated radiographic technique. Am J Surg. 1979;138:135–42.

    Article  CAS  PubMed  Google Scholar 

  10. Wertheim U, Ozzello L. Neoplastic involvement of nipple and skin flap in carcinoma of the breast. Am J Surg Pathol. 1980;4:543–9.

    Article  CAS  PubMed  Google Scholar 

  11. Andersen JA, Gram JB, Pallesen RM. Involvement of the nipple and areola in breast cancer. Value of clinical findings. Scand J Plast Reconstr Surg. 1981;15:39–42.

    CAS  PubMed  Google Scholar 

  12. Brachtel EF, Rusby JE, Michaelson JS, Chen LL, Muzikansky A, Smith BL, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27:4948–54.

    Article  PubMed  Google Scholar 

  13. Crowe JP, Patrick RJ, Yetman RJ, Djohan R. Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes. Arch Surg. 2008;143(11):1106–10.

    Article  PubMed  Google Scholar 

  14. 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;212:686–95.

    Article  PubMed  Google Scholar 

  15. Filho PA, Capko D, Barry JM, et al. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol. 2011;18:3117–22.

    Article  Google Scholar 

  16. Petit JY, Veronisi U, Orecchia R, et al. Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO). Breast Cancer Res Treat. 2009;117:333–8.

    Article  CAS  PubMed  Google Scholar 

  17. Tang R, Coopey SB, Merrill AL, et al. Positive nipple margins in nipple-sparing mastectomies: rates, management, and oncologic safety. J Am Coll Surg. 2016;222:1149–55.

    Article  PubMed  Google Scholar 

  18. Camp MS, Coopey SB, Tang R, et al. Management of positive sub-areolar/nipple duct margins in nipple-sparing mastectomies. Breast J. 2014;20:402–7.

    Article  PubMed  Google Scholar 

  19. Amara D, Peled AW, Wang F, et al. Tumor involvement of the nipple in total skin-sparing mastectomy: strategies for management. Ann Surg Oncol. 2015;22:3803–8.

    Article  PubMed  Google Scholar 

  20. Rusby JE, Brachtel EF, Othus M, et al. Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy. Br J Surg. 2008;95:1356–61.

    Article  CAS  PubMed  Google Scholar 

  21. Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20:3218–22.

    Article  PubMed  Google Scholar 

  22. 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.

    Article  PubMed  Google Scholar 

  23. Peled AW, Wang F, Foster FD, et al. Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease? Ann Surg Oncol. 2016;23:87–91.

    Article  PubMed  Google Scholar 

  24. 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.

    Article  PubMed  Google Scholar 

  25. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mastectomy with immediate implant reconstruction: cosmetic outcomes and technical refinements. Plast Reconstr Surg. 2010;126:1460–71.

    Article  CAS  PubMed  Google Scholar 

  26. Davies K, Allan L, Roblin P, Ross D, Farhadi J. Factors affecting post-operative complications following skin sparing mastectomy with immediate breast reconstruction. Breast. 2011;20:21–5.

    Article  PubMed  Google Scholar 

  27. NCCN Clinical Practice Guidelines: Breast cancer risk reduction v1.2016 [Internet]. Available from: https://wwwnccnorg/professionals/physician_gls/pdf/breast_riskpdf. 2016.

    Google Scholar 

  28. Hartmann LC, Sellers TA, Schaid DJ, et al. Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers. J Natl Cancer Inst. 2001;93:1633–7.

    Article  CAS  PubMed  Google Scholar 

  29. Yao K, Liederbach E, Tang R, et al. Nipple-sparing mastectomy in BRCA1/2 mutation carriers: an interim analysis and review of the literature. Ann Surg Oncol. 2015;22:370–6.

    Article  PubMed  Google Scholar 

  30. Peled AW, Irwin CS, Hwang ES, Ewing CA, Alvarado M, Esserman LJ. Total skin-sparing mastectomy in BRCA mutation carriers. Ann Surg Oncol. 2014;21:37–41.

    Article  PubMed  Google Scholar 

  31. Jakub J, Peled A, Gray R, et al. Multi-institutional study of the oncologic safety of prophylactic nipple-sparing mastectomy in a BRCA population [Abstract]. In: Proceedings from the 17th annual meeting of the American Society of Breast Surgeons. 2016 April 13–17, Dallas.

    Google Scholar 

  32. Coopey SB, Tang R, Rai U, et al. Oncologic safety of nipple sparing mastectomy in women with breast cancer [Abstract]. In: Proceedings from the 17th annual meeting of the American Society of Breast Surgeons. 2016 April 13–17, Dallas.

    Google Scholar 

  33. Peled AW, 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.

    Article  Google Scholar 

  34. 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.

    Article  PubMed  Google Scholar 

  35. Lohsiriwat V, Martella S, Rietjens M. Paget’s disease as a local recurrence after nipple-sparing mastectomy: clinical presentation, treatment, outcome, and risk factor analysis. Ann Surg Oncol. 2012;19:1850–5.

    Article  PubMed  Google Scholar 

  36. Orzalesi L, Casella D, Santi C, et al. Nipple sparing mastectomy: surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period. Breast. 2016;25:75–81.

    Article  PubMed  Google Scholar 

  37. De La Cruz L, Moody AM, Tappy EE, Blankenship SA, Hecht EM. Overall survival, disease-free survival, local recurrence, and nipple–areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review. Ann Surg Oncol. 2015;22:3241–9.

    Article  PubMed  Google Scholar 

  38. Gerber B, Krause A, Dieterich M, Kundt G, Reimer T. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249:461–8.

    Article  PubMed  Google Scholar 

  39. Benediktsson KP, Perbeck L. Survival in breast cancer after nipple sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;34:143–8.

    Article  CAS  PubMed  Google Scholar 

  40. Adam H, Bygdeson M, De Boniface J. The oncological safety of nipple-sparing mastectomy: a Swedish matched cohort study. Eur J Surg Oncol. 2014;40:1209–15.

    Article  CAS  PubMed  Google Scholar 

  41. Park SH, Han W, Yoo TK, et al. Oncologic safety of immediate breast reconstruction for invasive breast cancer patients: a matched case control study. J Breast Cancer. 2016;19:68–75.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Colwell AS, Gadd M, Smith BL, Austen WG. An inferolateral approach to nipple-sparing mastectomy. Ann Plast Surg. 2010;65:140–3.

    Article  CAS  PubMed  Google Scholar 

  43. Sacchini V, Pinotti JA, Barros ACSD, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203:704–14.

    Article  PubMed  Google Scholar 

  44. Harness JK, Vetter TS, Salibian AH. Areola and nipple–areola sparing mastectomy for breast cancer treatment and risk reduction: report of an initial experience in a community hospital setting. Ann Surg Oncol. 2011;18:917–22.

    Article  PubMed  Google Scholar 

  45. Djohan R, Gage E, Gatherwright J, et al. Patient satisfaction following nipple-sparing mastectomy and immediate breast reconstruction: an 8-year outcome study. Plast Reconstr Surg. 2010;125:818–29.

    Article  CAS  PubMed  Google Scholar 

  46. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg. 2014;133:496–506.

    Article  CAS  PubMed  Google Scholar 

  47. Robertson SA, Rusby JE, Cutress RI. Determinants of optimal mastectomy skin flap thickness. Br J Surg. 2014;101:899–911.

    Article  CAS  PubMed  Google Scholar 

  48. Rusby JE, Kirstein LJ, Brachtel EF, et al. Nipple-sparing mastectomy: lessons from ex vivo procedures. Breast J. 2008;14:464–70.

    Article  PubMed  Google Scholar 

  49. 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.

    Article  CAS  PubMed  Google Scholar 

  50. Lemaine V, Hoskin TL, Farley DR, et al. Introducing the SKIN score: a validated scoring system to assess severity of mastectomy skin flap necrosis. Ann Surg Oncol. 2015;22:2925–32.

    Article  PubMed  Google Scholar 

  51. Howard MA, Sisco M, Yao K, et al. Patient satisfaction with nipple-sparing mastectomy: a prospective study of patient reported outcomes using the BREAST-Q. J Surg Oncol. 2016;114:416–22.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Metcalfe KA, Cil TD, Semple JL, et al. Long-term psychosocial functioning in women with bilateral prophylactic mastectomy: does preservation of the nipple-areolar complex make a difference? Ann Surg Oncol. 2015;22:3324–30.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 7B, Boston, MA, 02114, USA

    Suzanne B. Coopey MD

  2. Division of Surgical Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9A, Boston, MA, 02114, USA

    Barbara L. Smith MD, PhD

Authors
  1. Suzanne B. Coopey MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Barbara L. Smith MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Suzanne B. Coopey MD .

Editor information

Editors and Affiliations

  1. Associate Professor of Surgery, Director Breast Care Center, Wake Forest School of Medicine, Winston-Salem, NC, USA

    Marissa Howard-McNatt

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Coopey, S.B., Smith, B.L. (2018). Nipple-Sparing Mastectomy. In: Howard-McNatt, M. (eds) Changing Paradigms in the Management of Breast Cancer . Springer, Cham. https://doi.org/10.1007/978-3-319-60336-0_2

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-60336-0_2

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-60335-3

  • Online ISBN: 978-3-319-60336-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation