A nipple-sparing mastectomy with immediate reconstruction removes breast tissue while preserving the overlying skin, areola, and nipple. This operation is a single surgical event, combining the mastectomy with the immediate rebuilding of the breast’s shape. The purpose is to treat or prevent breast cancer while optimizing the cosmetic result by maintaining the breast’s natural appearance. Preserving the complete skin envelope can reduce the psychological burden of a mastectomy and improve patient satisfaction.
Candidate Selection for the Procedure
A multidisciplinary team determines if a patient is a suitable candidate for a nipple-sparing mastectomy. Oncological safety and the potential for a good cosmetic outcome are the guiding factors in this decision. The process involves careful consideration of the tumor’s features, the patient’s anatomy, and their overall health.
Tumor characteristics are a primary consideration. The procedure is recommended for individuals with smaller tumors located away from the nipple-areolar complex. A distance of at least two centimeters between the tumor and the nipple is a common guideline to reduce the risk of leaving cancer cells behind. Patients with inflammatory breast cancer, Paget’s disease, or tumors involving the nipple or skin are not candidates due to oncological safety concerns.
The physical characteristics of the breast also factor into selection. Ideal candidates have small to moderate-sized breasts with minimal sagging (ptosis). Larger breasts or those with significant ptosis can present challenges, as the blood supply to the nipple may be compromised. A lower body mass index (BMI) is also preferred for better outcomes.
A patient’s general health and lifestyle are also reviewed. Individuals who do not smoke are preferred candidates because smoking constricts blood vessels and can impair healing of the preserved nipple tissue. The absence of medical conditions that affect circulation, such as severe diabetes or vascular disease, is also favorable. Patients who have not undergone previous radiation therapy to the breast are better suited, as radiation can affect tissue quality and healing.
The Surgical Process
The nipple-sparing mastectomy begins with an inconspicuous incision. Surgeons often place it in the fold under the breast (inframammary fold), along the side of the breast, or around the areola. The location is chosen to provide adequate access for tissue removal while minimizing visible scarring and preserving blood flow to the skin and nipple.
Following the incision, the surgeon removes the glandular breast tissue from beneath the skin envelope, leaving the skin, nipple, and areola intact. A thin layer of tissue directly under the nipple and areola is preserved to maintain their blood supply. As a safety measure, a sample of this tissue from behind the nipple is immediately sent to a pathologist for an intraoperative frozen section analysis to be examined for cancer cells.
Once the mastectomy is complete, the reconstructive phase begins immediately. The most common method is implant-based reconstruction, where a permanent silicone or saline implant is placed to create the new breast mound. In some cases, a temporary tissue expander is inserted first. This expander is gradually filled with saline over several weeks or months to stretch the skin and muscle, creating a pocket for a permanent implant in a later surgery.
An alternative to implants is autologous, or flap, reconstruction. This technique uses the patient’s own tissue, along with its blood supply, from another area of the body like the abdomen or thighs to create the new breast. While this is a more complex operation, it can create a more natural-feeling breast and avoids complications associated with implants. The choice between methods depends on the patient’s body type, health, and personal preference.
Recovery and Healing
The immediate post-operative period is spent in the hospital, with the length of stay depending on the reconstruction. For implant-based procedures, patients may go home the same day or stay overnight, while autologous flap reconstruction requires a longer stay. One or more surgical drains are placed to collect excess fluid from the surgical site. These drains remain for one to three weeks until the fluid output decreases to a specific level.
In the first few weeks at home, managing discomfort and restricting activity are the primary focus. Pain is controlled with medication, and many patients feel tightness or pressure in the chest. Patients are instructed to wear a supportive surgical bra and are given limitations on activities, such as avoiding heavy lifting and driving for several weeks. Gentle range-of-motion exercises are recommended to prevent stiffness in the chest and arm.
The longer-term healing process unfolds over several months. Most individuals return to work and light activities within three to six weeks. A return to more strenuous exercise takes longer, around six to eight weeks, once cleared by the surgical team. Follow-up appointments are scheduled to monitor the healing of incisions and ensure the reconstruction is proceeding as expected.
Potential Risks and Long-Term Outcomes
A primary risk specific to this procedure is nipple necrosis, the death of the preserved nipple and areola tissue from insufficient blood supply. This complication can range from partial to complete loss of the nipple. Factors like smoking, obesity, large breast size, and certain incision placements can increase this risk. Other standard surgical risks include infection, bleeding, and fluid collections (seromas or hematomas).
For patients with implant-based reconstruction, there are specific long-term considerations. A common issue is capsular contracture, where scar tissue around the implant tightens, causing the breast to feel hard and look distorted. Other potential problems include the implant shifting position or, in rare cases, rupture or extrusion. These complications may require additional surgeries to correct.
A long-term outcome is a change in sensation. The nerves providing feeling to the breast skin and nipple are severed during the mastectomy, resulting in numbness. While some minimal sensation may return over time, the nipple and breast will not feel the same as before surgery. Newer techniques are being explored to improve sensory recovery, but widespread numbness remains a common outcome.
Achieving the desired cosmetic appearance can be a process. While the goal is a natural-looking breast, symmetry with the other breast may not be perfect, and revision surgeries are sometimes needed to improve shape or position. For appropriately selected candidates, the risk of cancer recurrence in the breast or nipple area is low and comparable to other types of mastectomies.