A mastectomy is a surgical procedure used to treat breast cancer or reduce risk in individuals with a high genetic predisposition, such as a BRCA gene mutation. This surgery involves removing the breast tissue to eliminate or prevent disease. The nipple-sparing mastectomy (NSM) is a modern approach that balances oncological safety with aesthetic outcome. This technique removes all underlying glandular and fatty breast tissue while preserving the natural outer appearance, including the skin envelope, nipple, and areola.
Defining Nipple Sparing Mastectomy
Nipple Sparing Mastectomy (NSM) is a specialized surgical technique involving the complete removal of the breast’s internal tissue while preserving the entire skin envelope, including the Nipple Areola Complex (NAC). The primary objective is oncological safety, ensuring all at-risk or cancerous tissue is excised, while retaining the patient’s natural breast contour and appearance. Surgeons typically make a small incision, often placed discreetly beneath the breast or around the areola, through which the breast tissue is meticulously removed.
This procedure is almost always performed in collaboration with a plastic surgeon, allowing for immediate breast reconstruction. The preserved skin envelope and NAC create an optimal pocket for placing an implant or using the patient’s own tissue for reconstruction, leading to a more natural-looking result. To ensure safety, the subareolar tissue directly beneath the NAC is removed and sent for a margin check during surgery, analyzed by a pathologist to confirm no cancer cells are present.
How NSM Differs From Other Mastectomy Procedures
The defining difference between NSM and other mastectomy types lies in the anatomical structures that are preserved. A simple or total mastectomy involves removing the entire breast, including the glandular tissue, overlying skin, and the Nipple Areola Complex. This approach often results in a flat chest, requiring a fully reconstructed nipple and areola later.
A skin-sparing mastectomy saves most of the breast skin but still removes the nipple and areola, necessitating a reconstructed nipple. The NSM technique is considered the most advanced in aesthetic preservation, maintaining the skin, areola, and nipple intact. By keeping the entire outer breast structure, NSM provides a superior aesthetic outcome.
Determining Eligibility for Nipple Sparing Mastectomy
Patient selection for Nipple Sparing Mastectomy is based on strict medical criteria to ensure the procedure is safe and effective. Ideal candidates include individuals with small, early-stage tumors located far from the Nipple Areola Complex. It is also a highly preferred option for women undergoing prophylactic mastectomy for risk reduction, such as those with a BRCA gene mutation, who have no cancer at all.
Factors that may rule out a patient include inflammatory breast cancer, large tumors, or evidence of cancer involvement in or beneath the nipple or areola. Other contraindications are related to blood supply and healing, such as prior radiation treatment, smoking, or uncontrolled diabetes. Patients with very large breasts or significant ptosis (drooping) may also be less favorable candidates.
Recovery and Post-Surgical Considerations
Following NSM, recovery requires meticulous post-operative care. Patients typically have surgical drains placed to remove excess fluid from the surgical site, which usually remain in place for up to two weeks. Healing time varies, but patients are advised to restrict strenuous activity for several weeks to allow incisions to close and the reconstructed breast to settle.
A common reality following NSM is the alteration or loss of sensation in the preserved nipple and surrounding skin. During tissue removal, the sensory nerves that provide feeling are often disrupted. The majority of patients report their nipples are either totally numb or have significantly reduced sensation, though some may regain partial sensation over many months as nerves attempt to regenerate.