Web Log – February 2011 – Nipple Sparing Mastectomy

Bogus Basin View
Bogus Basin View

Plastic Surgery, like many disciplines, has operations which wax and wane in their popularity.  One of those is the nipple sparing mastectomy.

In the 1980’s, the operation was more commonly known as a subcutaneous mastectomy.  It was mainly offered to women who did not have cancer, but who did have severely fibrocystic breasts which were difficult to examine for potential cancers or who had intolerable breast pain (mastodynia).  As there was no cancer, there was no reason that the nipple had to be removed as well.  The nipple has elements of breast tissue, ducts, to direct milk out of the breast gland and into a baby’s hungry mouth.  It was therefore thought to be unsafe to leave the nipple because of the small amounts of breast tissue left behind.

While the subcutaneous mastectomy sounds like a great idea, I can tell you from first hand experience that the operation can have plenty of problems.  I have seen dozens of patients operated on in the 80’s and 90’s who had poor results.  I am also sure there are many women out there who had good results and have had no reason to see the plastic surgeon again.  The question is, why would some women have poor results while others had good results?  The answer is another common theme in plastic surgery: patient selection.

The subcutaneous mastectomy is back in recent years and has been much discussed in the recent literature and at our recent meeting.  I have seen that it is a good operation in the right setting.  What is different this time?  Now, it is being offered to patients with breast cancer.  Studies have found that patients with relatively small tumors far away from the nipple can have the nipple spared and still have an acceptably similar cure rate to a mastectomy including nipple removal.  This operation can only be offered by an experienced breast cancer surgeon who knows how to evaluate his or her patient.  The breast cancer surgeon must also be able to perform this more difficult operation well, or the remaining skin may contribute to post operative healing problems.

Once it has been determined that nipple sparing mastectomy would be a safe operation for a patient, she should then be evaluated by a plastic surgeon to assess if she would be likely to have an aesthetic result.  What I have found examining patients with poor results is reflected in the most recent literature.  Women with larger and more ptotic (droopy) breasts tend to have worse outcomes.  If you think of the breast as a bag, and the mastectomy empties the bag, a large and ptotic breast will have a further distance for blood flow to go to feed the nipple and the bag volume will be difficult to fill effectively.  Therefore, if women with smaller and less ptotic breasts are selected for the operation, they will be more likely to have a good result. The use of acellular dermis (see previous blogs) has also contributed to better recent outcomes.

The operation, of course, still has its problems.  There may be healing difficulties, infection, poor shape, implant visibility, and contracture.  The most common source of dissatisfaction in a recent survey, however, was decreased or absent nipple sensation.   In many ways, the operation has more risks than a mastectomy in which the nipple is removed, but the results of a successful nipple sparing mastectomy can be excellent and difficult to replicate with other techniques.

Don’t forget… The Boise Komen Race for the Cure is coming up on May 7th.  We have formed team Wigod Plastic Surgery again.  You can sign up to raise money for the cause to cure breast cancer and take part in the fun with us at:

https://boise.info-komen.org/site/TR/RacefortheCure/BOI_BoiseAffiliate?team_id=154775&pg=team&fr_id=2030

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