Whether women have mastectomy to prevent or treat breast cancer, most are candidates for nipple-sparing mastectomy. Individuals with very large tumors or tumors in or close to the nipple are not candidates for nipple-sparing procedures. Women with moderate to severe breast ptosis (sagging) are also routinely advised against nipple-sparing mastectomy. Ptosis develops when aging or gravity causes the breasts to sag (breast tissue contains no supportive muscle). Ptosis can also occur after pregnancy, breastfeeding or significant weight loss. Smoking also accelerates ptosis because it erodes skin elasticity.
In round, non-sagging (or minimally sagging) breasts, the retained nipple is more likely to end up where it should be after reconstruction: in the center of the new breast. Large, pendulous breasts tend to be low-hanging and oblong rather than round, with nipples that are positioned far south of center. They make nipple-sparing mastectomy difficult, because of the likelihood that the nipples cannot be appropriately positioned on the new breast.
It’s mostly a problem of excess skin.
Patients and surgeons don’t face the same issue when a traditional mastectomy is performed, because much of the excess breast skin that encloses the droopy breast can be removed along with the nipple and areola. But what do you do with all that excess skin when a nipple-sparing mastectomy leaves the nipple, areola and breast skin intact, and how do you elevate the nipple so that it is centered on the new breast?
It’s a problem that presents technical and aesthetic surgical challenges.
A recently-published study in the journal Plastic and Reconstructive Surgery introduces a new procedure that is specifically designed to provide nipple-sparing mastectomy as an option for women with ptotic breasts, as long as an oncologic reason doesn’t preclude them from having nipple-sparing mastectomy.
NSM + tissue flap + breast lift = NSM for low-hanging breasts
The new technique combines nipple-sparing mastectomy, perforator flap reconstruction and breast lift procedures. First, a breast surgeon who is experienced with nipple-sparing mastectomy removes the breast tissue through a periareolar (around the areola) incision. Then the reconstructive surgeon performs a perforator flap reconstruction, restoring volume from missing breast tissue with fatty tissue from a patient’s hip or abdomen. Finally, a full breast lift is performed on the reconstructed breast: the transferred flap of tissue is tightened and reshaped, excess skin is removed, and the incision is closed. The result is a newly-recreated breast with a correctly positioned natural nipple and areola.
Like all reconstructive surgeries, the new procedure requires appropriate surgical skill and experience to preserve adequate blood flow to the nipple. It’s a new concept and a new technique that will probably take a while to catch on.
DellaCroce J, Blum CA, Sullivan S K, et al. "Nipple Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction Allows Full Secondary Mastopexy with Complete Nipple Areolar Repositioning." Journal of Plastic and Reconstructive Surgery, July 2015; Vol. 136, Issue 1: p. 1e–9e.