Source:  Plastic and Reconstructive Surgery: November 2011, Vol. 128 Issue 5, P. 1005-1014.

Surgery for the treatment of breast cancer continues to evolve with modified versions of radical mastectomy (whole breast removal), to skin-sparing mastectomy (allowing for easier implant placement) to newer areola-sparing and nipple-sparing mastectomies.  The legitimate fear of disfigurement is a very real factor which likely prevents many more women from seeking timely screeing and treatment of breast cancer.   For all of its perceived brutality, mastectomy works.  For patients prone to certain aggressive forms of breast cancer a mastectomy can reduce an individual woman’s risk of breast cancer by 90 to 95%. 

Notwithstanding an improved cosmetic and psychological benefit to women, nipple-sparing mastectomy is still not widely offered to women who have been diagnosed with breast cancer and who require surgery.  A retrospective (looking back) review of 162 patients who underwent nipple-sparing mastectomy at Georgetown University Hospital’s Lombardi Comprehensive Cancer Center was conducted.

How the surgery is performed.  A combined surgery involving a plastic surgeon and breast surgeon begins with marking the patient to preserve the nipple and the majority of the aereola while allowing access to the underdyling breast tissue.  Thickness of the mastectomy flap is patient size dependant.  Care is taken to maintian sufficient fat tissue in the breast to improve appearance.  Cautery (burning) is used sparingly and the skin is handled with delicate hooks to minimize traction injury.  All breast ducts are removed without coring the nipple, preserving blood supply while the breast tissue is selectively removed.

The Results.  Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women. Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients.  Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised. With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex.  The remaining 113 mastectomies (70 percent) were performed prophylactically (preventative before any breast cancer diagnosis) on 80 patients. The subareolar tissue was biopsied in 80 breasts (71 percent). One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer. Two nipple-areola complexes (1.8 percent) were ischemic and excised. With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex.

Conclusion.  Nipple-sparing mastectomy appears to be a safe alternative to radical and other mastectomies for women diagnosed with or pre-disposed to breast cancer.  Further, instead of the traditional biopsy techniques, a subareolar biopsy can effectively identify nipple-areola complexes with cancer cells.  The advantages in terms of cosmetics and psychological well-being to such procedures make them worthy of discussion.

Posted by: David M. Schwadron, Esquire