The Nipple-Areola Complex (NAC) is a highly visible part of the breast often affected by breast cancer treatment. When a mastectomy is required, surgeons must balance oncological safety with preserving the breast’s cosmetic appearance. Whether the nipple is removed depends entirely on the type of surgery performed and the characteristics of the tumor. Understanding the surgical decision-making process is a meaningful step in treatment planning for patients concerned about the potential loss of the nipple.
When Nipple Removal is Necessary
In a traditional or simple mastectomy, the entire breast tissue, including the NAC, is removed to ensure the complete elimination of cancer cells. The nipple is connected to the underlying milk ducts, a common site for cancer development and spread. Removing the NAC is a standard procedure when the risk of leaving behind microscopic disease is too high.
Nipple removal is mandatory in specific medical situations to ensure a clear surgical margin. This includes tumors located centrally, directly beneath the nipple, or those invading the overlying skin. Advanced stages of breast cancer, such as inflammatory breast cancer, also necessitate the complete removal of the skin envelope when the disease involves the skin.
Certain diagnoses mandate NAC removal due to the nature of the disease. Paget’s disease, a rare cancer starting in the milk ducts and spreading to the nipple skin, requires removal of the entire complex. Extensive or multifocal Ductal Carcinoma In Situ (DCIS) that has spread widely also poses a high risk of residual disease. If an intraoperative biopsy of the tissue behind the nipple detects cancer cells, the nipple must be excised immediately.
Criteria for Nipple-Sparing Procedures
When tumor characteristics allow for safe removal without compromising cancer clearance, a Nipple-Sparing Mastectomy (NSM) may be performed. The goal of NSM is to remove all glandular tissue through a small incision while leaving the entire skin envelope, including the nipple and areola, intact. This technique significantly improves the aesthetic outcome of breast reconstruction.
Patient eligibility for NSM is determined by strict oncological criteria to prevent local recurrence. Ideal candidates typically have small, early-stage tumors located peripherally, several centimeters away from the NAC. Prophylactic mastectomy, performed on high-risk patients without active cancer, often presents the best scenario for preservation. Surgeons rely on advanced imaging and biopsy of the nipple margin to confirm the absence of malignant cells behind the NAC.
Several contraindications prevent the safe performance of an NSM, as patient safety takes precedence over cosmetic results. Women who have previously received radiation therapy or who are active smokers face an increased risk of poor blood supply and healing complications. These factors can lead to nipple necrosis, where the preserved tissue dies. Additionally, patients with large, aggressive, or locally advanced tumors are not considered suitable candidates for a nipple-sparing approach.
Options for Nipple Reconstruction
If the NAC is removed, patients have several options to restore the appearance of the breast mound once primary reconstruction is complete. The goal of nipple reconstruction is to recreate the shape, projection, and color of the missing complex. This is typically the final step in the breast reconstruction journey, often performed months after the initial surgery.
Surgical Reconstruction
One common option involves surgical reconstruction, where a plastic surgeon uses small local skin flaps from the reconstructed breast to create a projecting mound. This procedure recreates the physical shape, but the reconstructed nipple will not have sensation. A small skin graft from another part of the body may also be used to create the areola.
3D Tattooing
A non-surgical method is high-definition 3D tattooing, often performed by artists specializing in medical tattooing. This technique uses specialized pigments and shading to create the hyper-realistic illusion of a nipple and areola on the flat breast skin. The 3D tattoo offers a realistic appearance without the need for additional surgery.
External Prosthetics
External prosthetic nipples provide a temporary or non-invasive alternative for individuals who prefer not to undergo further procedures. These adhesive, stick-on options are typically made of silicone and are designed to be removable, offering a realistic look and texture. The choice of reconstruction method is a personal decision based on individual preferences for projection, color, and tolerance for additional surgery.