I’m Dr. Michael Dobryansky. I’m a board certified plastic surgeon and a partner in a Long Island plastic surgical group. A nipple sparing mastectomy is the type of a mastectomy that preserves basically the entire skin envelope of the breast. So all the skin and the areola and the nipple itself remain in place after the mastectomy is completed.
So there are many differences between skin sparing mastectomy and nipple sparing mastectomy, but in my mind, one of the most important ones is the most natural appearing results. A lot of patients come in and say that they want natural looking reconstruction. This is where a nipple sparing mastectomy typically comes in. A nipple sparing mastectomy looks and feels typically in the most natural way, and the closest way to the original breast. In fact, in a lot of patients, the results of a nipple sparing mastectomy truly approach the results of a breast augmentation when the woman, obviously, maintains her breast tissue, which is augmented either by an implant or another method.
The main advantages to the nipple sparing mastectomy are the preservation of the footprint, the size, the height, and the volume of the breast. So if a woman, who’s about to undergo a mastectomy, desires to keep the volume of her pre mastectomy breasts, the nipple sparing mastectomy usually allows for a direct to implant reconstruction, which can, in one step, maintain the volume and shape of the female breast.
Most of the sensory function of the nipple is lost after a nipple sparing mastectomy. The reason for that is because the nerve supply to the nipple comes towards the nipple within the substance of the breast. Nipple functions, such as arousal, such as sensitivity to cold, when a nipple becomes erect, is typically lost.
I am frequently asked where the incisions will be for a nipple sparing mastectomy? Obviously, there are many different choices for the incision, which depend on the size and volume of the breast, but typically speaking, an incision for a nipple sparing mastectomy is located in the inframammary fold, which is a fold where the breast tissue meets the chest wall. The cosmesis of that incision is such that it stays hidden most of the time and in most situations, and it is the most natural appearing reconstruction.
The nipple sparing mastectomy is effective in both treating and preventing breast cancer. However, not everyone is an excellent candidate for a nipple sparing mastectomy if they have a diagnosis of breast cancer. So when it comes to prevention, the nipple sparing mastectomy is effective and it has been shown to be equally effective to the skin sparing mastectomy, for example, in terms of how effective it is in preventing breast cancer. The tissue behind the areola and the nipple typically is biopsied separately during a nipple sparing mastectomy to make sure that there’s no cancer present in that specimen. In which case, obviously, the patient will no longer be a candidate for a nipple sparing mastectomy.
A good candidate for a nipple sparing mastectomy is a woman who is about to undergo a mastectomy for either preventative purposes, such as a BRCA1 or BRCA2 genetic carrier, or a woman who has a diagnosis of early or relatively early stage breast cancer, which is located more than two centimeters away from the nipple- areolar complex, is less than two centimeters in size, and has not metastasized to the lymph nodes. Also, it is important to note that the shape and the size of the original female breast does play a role in determining whether a woman is a good candidate for a nipple sparing mastectomy.
For example, a large breast with some droop, or ptosis as we say, may not be as good of a candidate for a one stage nipple sparing mastectomy because the blood supply to the nipple-areolar complex is what we call a watershed blood supply, which means that the blood supply to the top of the breast where the nipple- areolar complex are located, has to travel a pretty long distance from the base of the breast, since the blood supply from within the gland is gone when the gland is removed. Therefore, that blood supply can struggle in terms of providing adequate blood flow to the nipple.
So there have been some developments in two stage nipple sparing mastectomies when a woman undergoes a breast reduction procedure done with a fairly standard technique of breast reduction, approximately three to four weeks prior to the mastectomy. That allows for a smaller breast to be created, and then for the healing to take place so that the breast three to four weeks down the line can be treated as a breast without ptosis, and the woman can undergo a breast sparing mastectomy.
So the patients who are not good candidates for a nipple sparing mastectomy are patients with advanced disease. Either systemic disease that has progressed to either lymph node or distant organ metastases, where the patients with where the tumor itself is located within two centimeters of the nipple-areolar complex, or in the patients within whose tumor involves the nipple-areolar complex or involves skin, which again, upstages their diagnosis typically to stage three and above, and therefore, they are not good candidates for nipple sparing mastectomy.
So the mastectomy and a nipple sparing mastectomy is obviously a combination procedure which consists of the mastectomy itself and the reconstructive step. Usually, both surgeons, the surgeon performing the mastectomy and the surgeon performing the reconstruction, will meet together and talk with the patient before proceeding to the operating room, and then, obviously, the surgeon performing the mastectomy starts the operation. Most of us have established teams with the mastectomy surgeons, and the workflow is organized in such a way as to minimize the time that the patient spends under anesthesia.
So what that usually translates to is once the first mastectomy is completed, if their patient is undergoing a bilateral mastectomy, the reconstruction begins on the mastectomy, which is on the side where the mastectomy is finished, while the other mastectomy is going on. Obviously, this is done assuming complete oncologic safety and all the final steps of the reconstruction wait until any intraoperative pathology is reported such as frozen sections, lymph node biopsies, et cetera. So that the reconstructive surgeon is given the final word by the mastectomy surgeon that yes, it is safe to proceed.
A mastectomy will typically take anywhere from 45 minutes to two hours per side, and the reconstruction usually takes about the same if it is non-autologous. In other words, if the implants or tissue expanders are involved. Autologous reconstruction typically takes longer. It could take anywhere from three hours to longer, again, depending on what techniques are used.