Overview
Definition:
Nipple-sparing mastectomy (NSM) is a surgical technique that removes the breast tissue while preserving the nipple-areola complex (NAC)
This approach aims to achieve oncologic safety and improve aesthetic outcomes by allowing for immediate breast reconstruction with a more natural appearance.
Epidemiology:
The adoption of NSM has increased significantly, driven by advancements in surgical techniques, patient selection, and imaging
It is considered for a subset of breast cancer patients and those undergoing prophylactic mastectomy, particularly those with a low risk of NAC involvement.
Clinical Significance:
NSM offers a significant psychological and cosmetic benefit over traditional mastectomy by preserving the NAC, which is crucial for body image and sexual well-being
However, it necessitates careful patient selection and meticulous surgical technique to minimize oncologic risks and ensure adequate perfusion of the preserved NAC.
Selection Criteria
Patient Selection:
Ideal candidates have small to moderate breast size, minimal breast ptosis, and no direct tumor involvement of the nipple or areola
A comprehensive risk assessment, including genetic predisposition (e.g., BRCA mutations) and tumor characteristics, is vital.
Tumor Characteristics:
Tumors located in the peripheral breast tissue, at least 2 cm away from the nipple-areola complex, are generally considered suitable
Tumors involving the retroareolar region, Paget disease of the nipple, or inflammatory breast cancer are contraindications.
Imaging Assessment:
Preoperative imaging, including mammography, ultrasound, and MRI, should be used to assess tumor location, size, and extent, ensuring no retroareolar involvement
MRI is particularly useful for evaluating multifocal or multicentric disease and occult breast cancer.
Contraindications:
Absolute contraindications include Paget disease of the nipple, direct tumor invasion of the NAC, inflammatory breast cancer, and extensive intraductal component extending to the nipple
Relative contraindications include heavy smoking, significant ptosis requiring extensive NAC repositioning, and previous radiation to the breast.
Surgical Technique
Incision Types:
Common incision patterns include inframammary fold, periareolar, and superior elliptical incisions
The choice of incision influences NAC visibility, dissection plane, and potential for flap necrosis.
Dissection And Tissue Removal:
Careful dissection is performed to remove all glandular breast tissue while preserving the NAC
The key is to excise the tissue deep to the dermoglandular junction, ensuring a margin around the NAC pedicle
Subcutaneous mastectomy techniques are often employed.
Flap Creation:
The creation of well-vascularized dermal flaps is crucial for maintaining NAC perfusion
The thickness of these flaps needs to be optimized to balance oncologic safety and vascular supply
Excessive thinning can compromise perfusion.
Reconstruction Methods:
NSM is often combined with immediate breast reconstruction, typically using autologous tissue flaps (e.g., DIEP, TRAM) or breast implants
The choice depends on patient anatomy, preference, and oncologic factors.
Perfusion Assessment
Intraoperative Monitoring:
Intraoperative assessment of NAC perfusion is critical
Visual inspection for color, capillary refill, and turgor of the nipple and areola is performed
Doppler ultrasound or handheld Doppler probes can assess blood flow within the NAC pedicle.
Vital Stains:
Intravenous injection of vital stains like indocyanine green (ICG) can be used to assess vascularity
Fluorescein dye can also be injected and visualized under a Wood's lamp to evaluate NAC perfusion.
Postoperative Monitoring:
Close postoperative monitoring is essential
Serial assessment of NAC color, temperature, and turgor for signs of ischemia or necrosis is crucial
Pain, blistering, and discoloration are warning signs.
Management Of Compromise:
If perfusion compromise is identified, interventions may include revision of the flap, local wound care, hyperbaric oxygen therapy, or, in severe cases, complete removal of the NAC and subsequent reconstruction options.
Complications
Early Complications:
Common early complications include flap necrosis (partial or complete NAC involvement), seroma, hematoma, infection, and wound dehiscence
Delayed wound healing can also occur.
Late Complications:
Late complications may involve ectropion of the NAC, altered nipple sensation, asymmetry, implant-related issues (e.g., capsular contracture), and unsatisfactory aesthetic outcomes.
Oncologic Risks:
The primary oncologic concern is the risk of occult malignancy within the NAC or retroareolar region missed during selection or incomplete removal
Close follow-up and adjuvant therapy are essential.
Key Points
Exam Focus:
Understand the absolute and relative contraindications for NSM
Master the intraoperative techniques for assessing NAC perfusion
Differentiate between strategies for flap preservation and reconstruction.
Clinical Pearls:
Emphasize meticulous dissection and preservation of the vascular pedicle to the NAC
Consider multidisciplinary team discussions for complex cases
Patient education regarding risks and expected outcomes is paramount.
Common Mistakes:
Overestimating patient suitability, inadequate dissection leading to retroareolar involvement, or poor assessment of NAC perfusion
Failure to obtain adequate margins around the NAC in cases of suspicion.