Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope

Background: Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-Areolar complex preservation and permit greater control over nipple-Areolar complex position and skin envelope following autologous reconstruction. Methods: A retrospective analysis was conducted of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2). The authors were specifically interested in the incidence of mastectomy skin necrosis and nipple-Areolar complex necrosis and malposition following stage 2. Results: Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m²(range, 23.4 to 49.0 kg/m²) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-Areolar complex necrosis (n = 5, 8.2 percent), complete nipple-Areolar complex necrosis (n = 4, 6.6 percent), nipple-Areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series. Conclusion: Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.