Nipple sparing mastectomies have been utilized and described since the 1970’s where they were better known as subcutaneous mastectomies. The possibility of preserving the nipple and areola has become both compelling and controversial. As plastic surgeons at The Breast Center Park Meadows Cosmetic Surgery, we feel the oncologic considerations of nipple sparing mastectomy are best reserved for discussion with a patient’s oncologist or surgical oncologist. However, once the oncologic (cancer) considerations regarding nipple sparing mastectomy have been addressed, there are still plastic surgical considerations with regard to which patients are the best candidates for this procedure.
First, it is important to understand why the nipple and surrounding areola skin are traditionally taken during a mastectomy procedure for breast cancer. Because breast cancer often involves the milk ducts, all milk ducts are usually taken to remove all cancer cells. These milk ducts course through the breast itself, which is why the breast tissue is removed, but they exit the breast through the nipple and surrounding areola. Because milk ducts are present in the nipple and areola, this tissue is commonly removed during conventional mastectomies. However, because there is a relative paucity of actual studies supporting or refuting that breast cancers actually arise from the ducts of the nipple, many surgical oncologists have begun offering nipple sparing mastectomies to select patients. In this procedure, the skin of the breast along with the nipple and areola are left intact and only the underlying breast tissue is removed through a simple incision around the areola or beneath the breast.
Though nipple sparing mastectomy (NSM) is occurring at increasing rates throughout the country, it is still in its investigational stages of development. Though there is still much discussion surrounding who is and who is not a candidate for nipple sparing mastectomy, there is some tacit consensus about those patients who should not undergo NSM. Generally speaking, those patients with large tumors (greater than 4cm) and those patients whose tumors are close to the nipple (within 2cm) are NOT good candidates for NSM. Patients with lymph node involvement or multicentric disease (cancer in numerous areas of the breast) are also not good candidates. Women with small tumors, away from the nipple may be reasonable candidates, but the ultimate selection should be determined with the counsel of a medical and surgical oncologist.
In addition to women who have breast cancer (less than 4cm in size and away from the nipple) other patients are electing to undergo NSM. These patients include those who are at high risk of developing breast cancer at some point in the future, but have not yet been diagnosed with breast cancer. Patients who test positive for the “breast cancer gene”, BRCA1/2 gene mutations, women with a strong family history and women undergoing mastectomy for cancer and who wish to reduce the risk of breast cancer in the opposite breast by having a mastectomy of both breasts are all candidates for considering nipple sparing mastectomy. These are referred to as prophylactic (risk reducing) mastectomies. In these patients it is important that all breast tissue is removed to obtain the greatest reduction in the risk of developing breast cancer in the future. The removal of tissue from behind the nipple can result in alteration of blood supply to the nipple which in some instances can lead to necrosis (death of tissue) of the nipple and areola. For this reason, patients with smaller breasts (A to B cup size) are better candidates and tend to have a lower incidence of nipple necrosis after mastectomy. Patients who undergo NSM should understand that the nipple and areola that are spared will have no significant sensation after mastectomy. However, for small breasted women, the preservation of the nipple and areola can lead to a more natural appearance of the reconstructed breast.
Dr. Jeremy Williams and Dr. Christopher Williams performed the first nipple sparing DIEP flap reconstruction in the Colorado region. As the first surgeons to routinely perform bilateral DIEP flap reconstruction in Colorado, this represents an exciting “turn of the page” for women seeking to undergo mastectomy for cancer or for prophylactic reasons who desire the most sophisticated form of breast reconstruction available. It is important to understand that not every woman is a candidate for nipple sparing mastectomy (NSM) and that this determination should be made with the direct input of a medical/surgical oncologist. However, we do believe this procedure warrants consideration, especially in instances of risk reduction.
We’d love to start a dialog with you at The Breast Center Park Meadows Cosmetic Surgery regarding your breast cancer reconstruction. During this time, we can discuss all the options with you and see if you may be a candidate for a Nipple-Sparing Mastectomy as well. For more information, or to schedule a consultation, please call our office at 303.706.1100