Aesthetic Plastic Surgery

, Volume 43, Issue 2, pp 313–327 | Cite as

Comparative Study of Nipple–Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander–Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy

  • Hyungsuk Kim
  • Sun-June Park
  • Kyong-Je Woo
  • Sa Ik BangEmail author
Original Article Breast Surgery



Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple–areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander–implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM.


Patients who underwent immediate expander–implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire.


Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM.


We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors


Nipple-sparing mastectomy Skin-sparing mastectomy Breast reconstruction Nipple malposition Patient satisfaction 



None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Rusby JE, Smith BL, Gui GP (2010) Nipple-sparing mastectomy. Br J Surg 97:305–316CrossRefPubMedGoogle Scholar
  2. 2.
    Spear SL, Hannan CM, Willey SC, Cocilovo C (2009) Nipple-sparing mastectomy. Plast Reconstr Surg 123:1665–1673CrossRefPubMedGoogle Scholar
  3. 3.
    Metcalfe KA, Cil TD, Semple JL, Li LD, Bagher S, Zhong T, Virani S, Narod S, Pal T (2015) Long-term psychosocial functioning in women with bilateral prophylactic mastectomy: does preservation of the nipple-areolar complex make a difference? Ann Surg Oncol 22:3324–3330CrossRefPubMedGoogle Scholar
  4. 4.
    Jabor MA, Shayani P, Collins DR Jr, Karas T, Cohen BE (2002) Nipple-areola reconstruction: satisfaction and clinical determinants. Plast Reconstr Surg 110:457–463 (discussion 464-465) CrossRefPubMedGoogle Scholar
  5. 5.
    Didier F, Radice D, Gandini S, Bedolis R, Rotmensz N, Maldifassi A, Santillo B, Luini A, Galimberti V, Scaffidi E, Lupo F, Martella S, Petit JY (2009) Does nipple preservation in mastectomy improve satisfaction with cosmetic results, psychological adjustment, body image and sexuality? Breast Cancer Res Treat 118:623–633CrossRefPubMedGoogle Scholar
  6. 6.
    Garcia-Etienne CA, Cody Iii HS 3rd, Disa JJ, Cordeiro P, Sacchini V (2009) Nipple-sparing mastectomy: initial experience at the Memorial Sloan-Kettering Cancer Center and a comprehensive review of literature. Breast J 15:440–449CrossRefPubMedGoogle Scholar
  7. 7.
    Spear SL, Willey SC, Feldman ED, Cocilovo C, Sidawy M, Al-Attar A, Hannan C, Seiboth L, Nahabedian MY (2011) Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg 128:1005–1014CrossRefPubMedGoogle Scholar
  8. 8.
    Hartmann LC, Schaid DJ, Woods JE, Crotty TP, Myers JL, Arnold PG, Petty PM, Sellers TA, Johnson JL, McDonnell SK, Frost MH, Jenkins RB (1999) Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med 340:77–84CrossRefPubMedGoogle Scholar
  9. 9.
    Chen CM, Disa JJ, Sacchini V, Pusic AL, Mehrara BJ, Garcia-Etienne CA, Cordeiro PG (2009) Nipple-sparing mastectomy and immediate tissue expander/implant breast reconstruction. Plast Reconstr Surg 124:1772–1780CrossRefPubMedGoogle Scholar
  10. 10.
    Petit JY, Veronesi U, Orecchia R, Rey P, Martella S, Didier F, Viale G, Veronesi P, Luini A, Galimberti V, Bedolis R, Rietjens M, Garusi C, De Lorenzi F, Bosco R, Manconi A, Ivaldi GB, Youssef O (2009) Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO). Breast Cancer Res Treat 117:333–338CrossRefPubMedGoogle Scholar
  11. 11.
    Sacchini V, Pinotti JA, Barros AC, Luini A, Pluchinotta A, Pinotti M, Boratto MG, Ricci MD, Ruiz CA, Nisida AC, Veronesi P, Petit J, Arnone P, Bassi F, Disa JJ, Garcia-Etienne CA, Borgen PI (2006) Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg 203:704–714CrossRefPubMedGoogle Scholar
  12. 12.
    Gerber B, Krause A, Dieterich M, Kundt G, Reimer T (2009) The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg 249:461–468CrossRefPubMedGoogle Scholar
  13. 13.
    Salgarello M, Visconti G, Barone-Adesi L (2010) Nipple-sparing mastectomy with immediate implant reconstruction: cosmetic outcomes and technical refinements. Plast Reconstr Surg 126:1460–1471CrossRefPubMedGoogle Scholar
  14. 14.
    Cho JW, Yoon ES, You HJ, Kim HS, Lee BI, Park SH (2015) Nipple-areola complex necrosis after nipple-sparing mastectomy with immediate autologous breast reconstruction. Arch Plast Surg 42:601–607CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Lee KT, Pyon JK, Bang SI, Lee JE, Nam SJ, Mun GH (2013) Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy? J Plast Reconstr Aesthet Surg 66:1543–1550CrossRefPubMedGoogle Scholar
  16. 16.
    Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ (2008) Optimizing the total skin-sparing mastectomy. Arch Surg 143:38–45 (discussion 45) CrossRefPubMedGoogle Scholar
  17. 17.
    Regolo L, Ballardini B, Gallarotti E, Scoccia E, Zanini V (2008) Nipple sparing mastectomy: an innovative skin incision for an alternative approach. Breast 17:8–11CrossRefPubMedGoogle Scholar
  18. 18.
    de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS (2011) Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol 18:3117–3122CrossRefGoogle Scholar
  19. 19.
    Kim HJ, Park EH, Lim WS, Seo JY, Koh BS, Lee TJ, Eom JS, Lee SW, Son BH, Lee JW, Ahn SH (2010) Nipple areola skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction is an oncologically safe procedure: a single center study. Ann Surg 251:493–498CrossRefPubMedGoogle Scholar
  20. 20.
    Wagner JL, Fearmonti R, Hunt KK, Hwang RF, Meric-Bernstam F, Kuerer HM, Bedrosian I, Crosby MA, Baumann DP, Ross MI, Feig BW, Krishnamurthy S, Hernandez M, Babiera GV (2012) Prospective evaluation of the nipple-areola complex sparing mastectomy for risk reduction and for early-stage breast cancer. Ann Surg Oncol 19:1137–1144CrossRefPubMedGoogle Scholar
  21. 21.
    van Verschuer VM, Mureau MA, Gopie JP, Vos EL, Verhoef C, Menke-Pluijmers MB, Koppert LB (2016) Patient satisfaction and nipple-areola sensitivity after bilateral prophylactic mastectomy and immediate implant breast reconstruction in a high breast cancer risk population: nipple-sparing mastectomy versus skin-sparing mastectomy. Ann Plast Surg 77:145–152CrossRefPubMedGoogle Scholar
  22. 22.
    Voltura AM, Tsangaris TN, Rosson GD, Jacobs LK, Flores JI, Singh NK, Argani P, Balch CM (2008) Nipple-sparing mastectomy: critical assessment of 51 procedures and implications for selection criteria. Ann Surg Oncol 15:3396–3401CrossRefPubMedGoogle Scholar
  23. 23.
    Ou KW, Yu JC, Ho MH, Chiu WK, Ou KL, Chen TM, Chen SG (2015) Oncological safety and outcomes of nipple-sparing mastectomy with breast reconstruction: a single-centered experience in Taiwan. Ann Plast Surg 74(Suppl 2):S127–S131CrossRefPubMedGoogle Scholar
  24. 24.
    Colwell AS, Tessler O, Lin AM, Liao E, Winograd J, Cetrulo CL, Tang R, Smith BL, Austen WG Jr (2014) Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg 133:496–506CrossRefPubMedGoogle Scholar
  25. 25.
    Peled AW, Duralde E, Foster RD, Fiscalini AS, Esserman LJ, Hwang ES, Sbitany H (2014) Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction. Ann Plast Surg 72(Suppl 1):S48–S52PubMedGoogle Scholar
  26. 26.
    Warren Peled A, Foster RD, Stover AC, Itakura K, Ewing CA, Alvarado M, Hwang ES, Esserman LJ (2012) Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol 19:3402–3409CrossRefPubMedGoogle Scholar
  27. 27.
    Boneti C, Yuen J, Santiago C, Diaz Z, Robertson Y, Korourian S, Westbrook KC, Henry-Tillman RS, Klimberg VS (2011) Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg 212:686–693 (discussion 693-695) CrossRefPubMedGoogle Scholar
  28. 28.
    Sbitany H, Wang F, Peled AW, Alvarado M, Ewing CA, Esserman LJ, Foster RD (2016) Tissue expander reconstruction after total skin-sparing mastectomy: defining the effects of coverage technique on nipple/areola preservation. Ann Plast Surg 77:17–24CrossRefPubMedGoogle Scholar
  29. 29.
    Niemeyer M, Paepke S, Schmid R, Plattner B, Muller D, Kiechle M (2011) Extended indications for nipple-sparing mastectomy. Breast J 17:296–299CrossRefPubMedGoogle Scholar
  30. 30.
    Burdge EC, Yuen J, Hardee M, Gadgil PV, Das C, Henry-Tillman R, Ochoa D, Korourian S, Suzanne Klimberg V (2013) Nipple skin-sparing mastectomy is feasible for advanced disease. Ann Surg Oncol 20:3294–3302CrossRefPubMedGoogle Scholar
  31. 31.
    Mori H, Uemura N, Okazaki M, Nakagawa T, Sato T (2016) Nipple malposition after nipple-sparing mastectomy and expander-implant reconstruction. Breast Cancer 23:740–744CrossRefPubMedGoogle Scholar
  32. 32.
    Small K, Kelly KM, Swistel A, Dent BL, Taylor EM, Talmor M (2014) Surgical treatment of nipple malposition in nipple-sparing mastectomy device-based reconstruction. Plast Reconstr Surg 133:1053–1062CrossRefPubMedGoogle Scholar
  33. 33.
    Spear SL, Albino FP, Al-Attar A (2013) Classification and management of the postoperative, high-riding nipple. Plast Reconstr Surg 131:1413–1421CrossRefPubMedGoogle Scholar
  34. 34.
    Troy JS, Chung S, Dayicioglu D (2015) Precision nipple positioning after nipple sparing mastectomy with hydrocolloid nipple adjuster. J Plast Reconstr Aesthet Surg 68:e15–e17CrossRefPubMedGoogle Scholar
  35. 35.
    Munhoz AM, Aldrighi C, Montag E, Arruda E, Aldrighi JM, Filassi JR, Ricci M, Brasil JA, Rezende V, Ferreira MC (2009) Optimizing the nipple-areola sparing mastectomy with double concentric periareolar incision and biodimensional expander-implant reconstruction: aesthetic and technical refinements. Breast 18:356–367CrossRefPubMedGoogle Scholar
  36. 36.
    Salgarello M, Visconti G, Barone-Adesi L, Franceschini G, Masetti R (2015) Contralateral breast symmetrisation in immediate prosthetic breast reconstruction after unilateral nipple-sparing mastectomy: the tailored reduction/augmentation mammaplasty. Arch Plast Surg 42:302–308CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Authors and Affiliations

  • Hyungsuk Kim
    • 1
  • Sun-June Park
    • 2
  • Kyong-Je Woo
    • 3
  • Sa Ik Bang
    • 2
    Email author
  1. 1.Department of Plastic SurgeryChoonhae HospitalBusanSouth Korea
  2. 2.Department of Plastic Surgery, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulSouth Korea
  3. 3.Department of Plastic Surgery, College of MedicineEwha Womans UniversitySeoulSouth Korea

Personalised recommendations