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Nipple-Sparing Mastectomy: To Spare Or Not To Spare?


The use of nipple-sparing mastectomy for prophylactic and therapeutic purposes has increased in recent years primarily driven by patient desire for improved esthetics. This article aims to critically review indications, oncologic safety, and recent advances in operative techniques. Current strategies for minimizing complications of nipple-sparing mastectomy are discussed including incision choices, adjunct tactics, and our experience.

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  1. 1.

    Agarwal S, Agarwal S, Neumayer L, Agarwal JP. Therapeutic nipple-sparing mastectomy: trends based on a national cancer database. Am J Surg. 2014;208(1):93–8. doi:10.1016/j.amjsurg.2013.09.030.

    Article  PubMed  Google Scholar 

  2. 2.

    Thomas TG. On the removal of benign tumors of the mamma without mutilation of the organe. Med J Obs Rev. 1882;35:337.

    Google Scholar 

  3. 3.

    Will BY, Bartlett RD. An anatomic substitute for the female breast. Ann Surg. 1917;66(2):208–11.

    Article  Google Scholar 

  4. 4.

    Hartmann LC, Schaid DJ, Woods JE, et al. Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer. N Engl J Med. 1999;340(2):77–84. doi:10.1056/NEJM199901143400201.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Yugueros P, Bite U. Current concepts and techniques in subcutaneous mastectomy. Oper Tech Gen Surg. 2000;2(2):110–7. doi:10.1053/otgn.2000.7815.

    Article  Google Scholar 

  6. 6.

    Pennisi VRCA. The incidence of obscure carcinoma in subcutaneous mastectomy. Results of a national survey. Plast Reconstr Surg. 1975;56(1):9–12.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Benediktsson KP, Perbeck L. Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 years median follow-up in 216 patients. Eur J Surg Oncol. 2008;32(2):143–8. doi:10.1016/j.ejso.2007.06.010.

    Article  Google Scholar 

  8. 8.

    Atkins K. Practical breast pathology: a diagnostic approach. Philadelphia: Saunders; 2013.

    Google Scholar 

  9. 9.

    Askew JB. Nipple micro-anatomy: ductal epithelial types. J Am Coll Surg. 2012;214(3):377. doi:10.1016/j.jamcollsurg.2011.12.004.

    Article  PubMed  Google Scholar 

  10. 10.

    Rosen P. Rosen’s Breast Pathology. 4th ed. Philadelphia: Lippincott, Willams & Wilkins; 2001.

    Google Scholar 

  11. 11.

    Reynolds C, Davidson JA, Lindor NM, Glazebrook KN, Jakub JW, Degnim AC, Sandhu NP, Walsh MF, Hartmann LC, Boughey JC. Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved? Ann Surg Oncol. 2011;18(11):3102–9. doi:10.1245/s10434-011-1908-8.

    Article  PubMed  Google Scholar 

  12. 12.

    Rosen PP, Tench W. Lobules in the nipple. Frequency and significance for breast cancer treatment. Pathol Annu. 1985;20(Pt 2):317–322.

  13. 13.

    Stolier AJ, Wang J. Terminal duct lobular units are scarce in the nipple: implications for prophylactic nipple-sparing mastectomy: terminal duct lobular units in the nipple. Ann Surg Oncol. 2008;15(2):438–42. doi:10.1245/s10434-007-9568-4.

    Article  PubMed  Google Scholar 

  14. 14.

    Torresan RZ, dos Santos CC, Okamura H, Alvarenga M. Evaluation of residual glandular tissue after skin-sparing mastectomies. Ann Surg Oncol. 2005;12(12):1037–44. doi:10.1245/ASO.2005.11.027.

    Article  PubMed  Google Scholar 

  15. 15.

    Crowe JP, Kim JA, Yetman R, Banbury J, Patrick RJ, Baynes D. Nipple-sparing mastectomy: technique and results of 54 procedures. Arch Surg. 2004;139:148–50. doi:10.1001/archsurg.139.2.148.

    Article  PubMed  Google Scholar 

  16. 16.

    Vlajcic Z, Zic R, Stanec S, Lambasa S, Petrovecki M, Stanec Z. Nipple-areola complex preservation: predictive factors of neoplastic nipple-areola complex invasion. Ann Plast Surg. 2005;55(3):240–4. doi:10.1097/

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Spear SL, Willey SC, Feldman ED, et al. Nipple-sparing mastectomy for prophylactic and therapeutic indications. Plast Reconstr Surg. 2011;128(5):1005–14. doi:10.1097/PRS.0b013e31822b6456.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Wijayanayagam A, Kumar AS, Foster RD, Esserman LJ. Optimizing the total skin-sparing mastectomy. Arch Surg. 2008;143(1):38–45. doi:10.1001/archsurg.2007.14 discussion 45.

    Article  PubMed  Google Scholar 

  19. 19.

    Brachtel EF, Rusby JE, Michaelson JS, et al. Occult nipple involvement in breast cancer: clinicopathologic findings in 316 consecutive mastectomy specimens. J Clin Oncol. 2009;27(30):4948–54. doi:10.1200/JCO.2008.20.8785.

    Article  PubMed  Google Scholar 

  20. 20.

    Rusby JE, Brachtel EF, Othus M, Michaelson JS, Koerner FC, Smith BL. Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy. Br J Surg. 2008;95:1356–61. doi:10.1016/S1043-321X(09)79281-1.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Lohsiriwat V, Petit J. Nipple Sparing Mastectomy: from prophylactic to therapeutic standard. Gland Surg. 2012;1(2):75–9. doi:10.3978/j.issn.2227-684X.2012.06.02.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Paepke S, Schmid R, Fleckner S, et al. Subcutaneous mastectomy with conservation of the nipple-areola skin: broadening the indications. Ann Surg. 2009;250(2):288–92. doi:10.1097/SLA.0b013e3181b0c7d8.

    Article  PubMed  Google Scholar 

  23. 23.

    • Krajewski AC, Boughey JC, Degnim AC, et al. Expanded Indications and Improved Outcomes for Nipple- Sparing Mastectomy Over Time. Ann Surg Oncol. 2015;22:3317–23. doi:10.1245/s10434-015-4737-3. Study of NSM demonstrating the recent evolution in the practice of NSM with expanded indications in terms of patient characteristics, tumor stage, prior surgery and radiation concomitant with decrease in complication rates.

  24. 24.

    Coopey SB, Tang R, Lei L, et al. Increasing eligibility for nipple-sparing mastectomy. Ann Surg Oncol. 2013;20(10):3218–22. doi:10.1245/s10434-013-3152-x.

    Article  PubMed  Google Scholar 

  25. 25.

    Fortunato L, Loreti A, Andrich R, et al. When mastectomy is needed: is the nipple-sparing procedure a new standard with very few contraindications? J Surg Oncol. 2013;108:207–12. doi:10.1002/jso.23390.

    Article  PubMed  Google Scholar 

  26. 26.

    Billar JAY, Dueck AC, Gray RJ, Wasif N, Pockaj BA. Preoperative predictors of nipple-areola complex involvement for patients undergoing mastectomy for breast cancer. Ann Surg Oncol. 2011;18(11):3123–8. doi:10.1245/s10434-011-2008-5.

    Article  PubMed  Google Scholar 

  27. 27.

    • Peled AW, Wang F, Foster RD, et al. Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease? Ann Surg Oncol. 2016;23(1):87–91. doi:10.1245/s10434-015-4734-6. Retrospective review of patients undergoing NSM for Stage II and III breast cancer demonstrating low rates of local recurrence.

  28. 28.

    Frederick MJ, Lin AM, Neuman R, Smith BL, Austen WG, Colwell AS. Nipple-sparing mastectomy in patients with previous breast surgery. Plast Reconstr Surg. 2015;135(6):954e–62e. doi:10.1097/PRS.0000000000001283.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Murphy BL, Hoskin TL, Boughey JC, Degnim AC, Jakub JW, Krajewski AC, Jacobson SR Hieken TJ. Outcomes and feasibility of nipple-sparing mastectomy for node-positive breast cancer patients. J Clin Oncol. 2015;33:suppl 28S; abstr 60.

  30. 30.

    Hartmann LC, Sellers TA, Schaid DJ, Frank TS, Soderberg CL, Sitta DL, Frost MH, Grant CS, Donohue JH, Woods JE, McDonnell SK. Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers. J Natl Cancer Inst. 2001;93(21):1633–7. doi:10.1093/jnci/93.21.1633.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Peled AW, Irwin CS, Hwang ES, Ewing CA, Alvarado M, Esserman LJ. Total skin-sparing mastectomy in BRCA mutation carriers. Ann Surg Oncol. 2014;21(1):37–41. doi:10.1245/s10434-013-3230-0.

    Article  PubMed  Google Scholar 

  32. 32.

    Heemskerk-Gerritsen BAM, Brekelmans CTM, Menke-Pluymers MBE, et al. Prophylactic mastectomy in BRCA1/2 mutation carriers and women at risk of hereditary breast cancer: long-term experiences at the Rotterdam Family Cancer Clinic. Ann Surg Oncol. 2007;14(12):3335–44. doi:10.1245/s10434-007-9449-x.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Yao K, Liederbach E, Tang R, et al. Nipple-Sparing mastectomy in BRCA1/2 mutation carriers: an interim analysis and review of the literature. Ann Surg Oncol. 2014;22(2):370–6. doi:10.1245/s10434-014-3883-3.

    Article  PubMed  Google Scholar 

  34. 34.

    Meijers-Heijboer H, van Geel B, van Putten WL, et al. Breast cancer after prophylactic bilateral mastectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2001;345(3):159–64. doi:10.1056/NEJM200107193450301.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    de Alcantara Filho P, Capko D, Barry JM, Morrow M, Pusic A, Sacchini VS. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol. 2011;18(11):3117–22. doi:10.1245/s10434-011-1974-y.

    Article  PubMed  Google Scholar 

  36. 36.

    Algaithy ZK, Petit JY, Lohsiriwat V, et al. Nipple sparing mastectomy: can we predict the factors predisposing to necrosis? Eur J Surg Oncol. 2012;38(2):125–9. doi:10.1016/j.ejso.2011.10.007.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Garwood ER, Moore D, Ewing C, et al. Total skin-sparing mastectomy: complications and local recurrence rates in 2 cohorts of patients. Ann Surg. 2009;249(1):26–32. doi:10.1097/SLA.0b013e31818e41a7.

    Article  PubMed  Google Scholar 

  38. 38.

    Peled AW, Foster RD, Stover AC, et al. Outcomes after total skin-sparing mastectomy and immediate reconstruction in 657 breasts. Ann Surg Oncol. 2012;19(11):3402–9. doi:10.1245/s10434-012-2362-y.

    Article  Google Scholar 

  39. 39.

    Garcia-etienne CA, Iii HSC, Disa JJ, Cordeiro P, Sacchini V. Nipple-sparing mastectomy: initial experience at the memorial sloan-kettering cancer center and a comprehensive review of literature. Breast J. 2009;15(1):440–9. doi:10.1111/j.1524-4741.2009.00758.x.

    Article  PubMed  Google Scholar 

  40. 40.

    Seth AK, Hirsch EM, Fine NA, et al. Additive risk of tumescent technique in patients undergoing mastectomy with immediate reconstruction. Ann Surg Oncol. 2011;18(11):3041–6. doi:10.1245/s10434-011-1913-y.

    Article  PubMed  Google Scholar 

  41. 41.

    Chun YS, Verma K, Rosen H, et al. Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction. Am J Surg. 2011;201(2):160–5. doi:10.1016/j.amjsurg.2009.12.011.

    Article  PubMed  Google Scholar 

  42. 42.

    Wapnir I, Dua M, Kieryn A, et al. Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies. Ann Surg Oncol. 2014;21(1):100–6. doi:10.1245/s10434-013-3214-0.

    Article  PubMed  Google Scholar 

  43. 43.

    Duggal CS, Madni T, Losken A. An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction. Aesthet Surg J. 2014;34:61–5. doi:10.1177/1090820X13514995.

    Article  PubMed  Google Scholar 

  44. 44.

    Dua MM, Bertoni DM, Nguyen D, Meyer S, Gurtner GC, Wapnir IL. Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland Surg. 2015;4(6):497–505. doi:10.3978/j.issn.2227-684X.2015.04.15.

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Christin A. Harless; Steven R. Jacobson. Tailoring through technology: A retrospective review of a single surgeon’s experience with implant-based breast reconstruction before and after implementation of Laser-Assisted Indocyanine Green Angiography. The Breast. 2016;(In Press).

  46. 46.

    Gdalevitch P, Van Laeken N, Bahng S, et al. Effects of nitroglycerin ointment on mastectomy flap necrosis in immediate breast reconstruction: a randomized controlled trial. Plast Reconstr Surg. 2015;135(6):1530–9. doi:10.1097/PRS.0000000000001237.

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Eriksson M, Anveden L, Celebioglu F, et al. Radiotherapy in implant-based immediate breast reconstruction: risk factors, surgical outcomes, and patient-reported outcome measures in a large Swedish multicenter cohort. Breast Cancer Res Treat. 2013;142:591–601. doi:10.1007/s10549-013-2770-0.

    Article  PubMed  Google Scholar 

  48. 48.

    Tang R, Coopey SB, Colwell AS, et al. Nipple-sparing mastectomy in irradiated breasts: selecting patients to minimize complications. Ann Surg Oncol. 2015;22(10):3331–7. doi:10.1245/s10434-015-4669-y.

    Article  PubMed  Google Scholar 

  49. 49.

    Petit JY, Veronesi U, Orecchia R, et al. Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia. Ann Oncol. 2012;23(8):2053–8. doi:10.1093/annonc/mdr566.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Stanec Z, Žic R, Budi S, et al. Skin and nipple-areola complex sparing mastectomy in breast cancer patients: 15-year experience. Ann Plast Surg. 2014;73(5):485–91. doi:10.1097/SAP.0b013e31827a30e6.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Mallon P, Feron J-G, Couturaud B, et al. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg. 2013;131(5):969–84. doi:10.1097/PRS.0b013e3182865a3c.

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    • Sakurai T, Zhang N, Suzuma T, et al. Long-term follow-up of nipple-sparing mastectomy without radiotherapy: a single center study at a Japanese institution. Med Oncol. 2013;30(1):481. doi:10.1007/s12032-013-0481-3. This study reported the longest follow up to date (median 78 months) of 788 pateints undergoing NSM without radiotherapy demonstrating no difference in 21-year overall or disease free survival between the NSM cohort and mastecomy cohort.

  53. 53.

    Lemaine V, Hoskin TL, Farley DR, et al. Introducing the SKIN score: a validated scoring system to assess severity of mastectomy skin flap necrosis. Ann Surg Oncol. 2015;22(9):2925–32. doi:10.1245/s10434-015-4409-3.

    Article  PubMed  Google Scholar 

  54. 54.

    Jensen JA, Orringer JS, Giuliano AE. Nipple-sparing mastectomy in 99 patients with a mean follow-up of 5 years. Ann Surg Oncol. 2011;18(6):1665–70. doi:10.1245/s10434-010-1475-4.

    Article  PubMed  Google Scholar 

  55. 55.

    Boneti C, Yuen J, Santiago C, et al. Oncologic safety of nipple skin-sparing or total skin-sparing mastectomies with immediate reconstruction. J Am Coll Surg. 2011;212(4):686–93. doi:10.1016/j.jamcollsurg.2010.12.039 discussion 693–695.

    Article  PubMed  Google Scholar 

  56. 56.

    Kim HJ, Park EH, Lim WS, et al. Nipple areola skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction is an oncologically safe procedure: a single center study. Ann Surg. 2010;251(3):493–8. doi:10.1097/SLA.0b013e3181c5dc4e.

    Article  PubMed  Google Scholar 

  57. 57.

    Petit JY, Veronesi U, Rey P, et al. Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat. 2009;114(1):97–101. doi:10.1007/s10549-008-9968-6.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Gerber B, Krause A, Dieterich M, Kundt G, Reimer T. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg. 2009;249(3):461–8. doi:10.1097/SLA.0b013e31819a044f.

    Article  PubMed  Google Scholar 

  59. 59.

    Sakamoto N, Fukuma E, Higa K, et al. Early results of an endoscopic nipple-sparing mastectomy for breast cancer. Indian J Surg Oncol. 2010;1(3):232–9. doi:10.1007/s13193-011-0057-7.

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Sacchini V, Pinotti JA, Barros ACSD, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg. 2006;203(5):704–14. doi:10.1016/j.jamcollsurg.2006.07.015.

    Article  PubMed  Google Scholar 

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Correspondence to James W. Jakub.

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Drs. Chiba, Jakub, and Hieken declare no conflicts of interest.

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This article is part of the Topical Collection on Breast Cancer Surgery.

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Chiba, A., Jakub, J.W. & Hieken, T.J. Nipple-Sparing Mastectomy: To Spare Or Not To Spare?. Curr Surg Rep 4, 17 (2016).

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  • Nipple-sparing mastectomy
  • Total skin-sparing mastectomy
  • NAC preservation
  • Breast cancer
  • Prophylactic mastectomy
  • Subcutaneous mastectomy
  • Local recurrence
  • Risk reduction
  • Inframammary
  • SPY