Nipple-sparing Mastectomy and Ptosis: Using a Free Nipple Graft with Tissue Expander Reconstruction

Abstract

Background: Nipple-sparing mastectomies are increasingly offered to women with breast cancer given the evidence for oncologic safety and improved cosmetic outcomes. Women with significant ptosis are often excluded due to potential nipple malposition and increased risk of nipple ischemia. The use of a harvested free nipple graft may allow women with ptosis to conserve their nipple -areolar complex. Methods: This is an IRB approved retrospective study of breast cancer patients at an academic center with ptosis who underwent free-nipple graft mastectomies with a single plastic surgeon and 5 dedicated breast surgeons from 2014-2017. The primary outcomes were free nipple graft viability and the need for revision. Secondary outcomes included post-operative complications. Results: Fourteen women with ptosis underwent skin and nipple-sparing mastectomy with breast reconstruction involving use of harvested free-nipple graft. More than half of the women were diagnosed with early-stage invasive breast cancer (42% stage 1, 14% stage 2). Four women underwent mastectomy for prophylaxis or other benign reasons. All of the women had significant ptosis during the pre-operative evaluation (57% grade 2 ptosis, 36% grade 3 ptosis, and 7% uncategorized), with an average BMI of 30. None were active smokers. In the postoperative period, one had partial nipple necrosis in combination with skin flap necrosis and positive margin (7%). Other complications included infection (14%) and hypopigmentation (14%). All nipples lost sensation and full projection. Conclusions: This is a novel approach using a free nipple graft with a skin envelope reducing mastectomy and immediate expander-based reconstruction. This successful approach allows women with ptosis to undergo nipple-sparing mastectomy with preservation of the nipple -areolar complex.

Free Nipple Graft Breast Reduction without a Vertical Incision

“…Additionally, it is possible to perform a mastectomy and contralateral reduction utilizing the same type of incision for aesthetic purposes. 20,21 The principal investigator has found that this technique can be performed more rapidly with less blood loss, and patients are usually discharged on the same day, even if an excess of 1000 grams of tissue has been removed.…”

“…Additionally, it is possible to perform a mastectomy and contralateral reduction utilizing the same type of incision for aesthetic purposes. 20,21 The principal investigator has found that this technique can be performed more rapidly with less blood loss, and patients are usually discharged on the same day, even if an excess of 1000 grams of tissue has been removed. The disadvantages of performing a free nipple graft include a loss of nipple sensation, the inability to breastfeed, and the fact that the nipple graft utilizes imbibition for vascular supply initially.…”

Outcomes of Nipple-Sparing Mastectomy in the Ptotic and Non-Ptotic Breast with Staged-Immediate Reconstruction Timing and Pre-Pectoral, Direct-to-Implant Technique

“…In addition, NSM incision patterns and their use tend to change over time, contributing to improved cosmetic outcomes [2]. Unfortunately, women with breast ptosis are often not considered for NSM due to the increased risk of nipple ischemia and nipple-areolar complex (NAC) malposition [3][4][5]. The popularity and benefits of NSM have produced an increasing need to offer this mastectomy technique to the breast ptosis patient population.…”

Staged Approach to Autologous Reconstruction in the Ptotic Breast

“…5 In an effort to broaden the indications for NSM, surgeons have developed a variety of techniques to be able to offer nipple preservation in the ptotic breast. 5,[7][8][9][10][11][12] Specifically, staged procedures have been shown to mitigate the ischemic complications of the NAC with NSM technique. [8][9][10][13][14][15] Our authors sought to offer the combination of techniques that have been shown to provide higher patients satisfaction and quality of life, namely, NSM and autologous breast reconstruction.…”

“…In addition, skin redundancy is problematic from an aesthetic standpoint resulting in poor control over breast shape, contour, nipple position, and symmetry 5 . In an effort to broaden the indications for NSM, surgeons have developed a variety of techniques to be able to offer nipple preservation in the ptotic breast 5,7–12 . Specifically, staged procedures have been shown to mitigate the ischemic complications of the NAC with NSM technique 8–10,13–15 …”