ASO Author Reflections: Preventing Nipple Loss by Surgical Delay in Nipple-Sparing Mastectomy

Abstract

Subcutaneous mastectomies performed in the 1960s preserved the skin envelope of the breast as well as the nipple-areolar complex (NAC). Breast reconstruction with early implant technology was rudimentary by today’s standards and therefore considerable amounts of breast tissue were left behind to create a normal appearing breast. Consequently, high recurrence rates of breast cancer were noted, leading to the abandonment of this approach for decades. Nipple-sparing mastectomies (NSM) were reintroduced in the 1990s with oncological principles of removing all breast tissue at risk in the manner of total mastectomies while permitting preservation of the defining element of the breast: the NAC. However, despite the numerous advantages of NAC preservation, reported contraindications were fairly broad, including breast ptosis and macromastia, smoking, and history of radiotherapy. Thus, a large number of patients were excluded a priori from experiencing the potential benefits of NAC preservation. The main reason for this rather conservative approach to NSM were concerns regarding ischemic complications. Since then, we have gained considerable knowledge regarding the vascular anatomy of the NAC, with identification of distinct vascular patterns that predispose patients to developing ischemic complications following one-stage NSM. An alternative approach to circumventing ischemic complications after NSM is through a preemptive staging operation, surgical delay otherwise known as devascularization of the NAC. Importantly, implementation of principles of surgical delay permit a change in the risk profile of these high-risk patients with a staged NAC delay followed by NSM, thereby reducing ischemic complications.