Nipple-Sparing Mastectomy Questions Answered

Nipple-sparing mastectomy is a relatively new reconstruction option for women undergoing mastectomies. To find out just what nipple-sparing mastectomy entails and who is or is not a candidate, I went right to the experts. Following are questions I submitted and the answers graciously provided by Russell Novak, MD, FACS, of Sarasota Surgical Specialists and Alissa Schulman, MD, FACS, of Sovereign Plastic Surgery.

1. What is a nipple-sparing mastectomy?

This is a mastectomy in which the breast tissue is removed, and the entire (skin) envelope is  left intact.  It saves the nipple and areola, where prior mastectomies did not.

2. How is the procedure done, in simple terms?

An incision (cut) is made from underneath the breast (fold) and the entire contents (breast tissue) are removed.  We use a special “electric blade” (Plasmablade) to carefully remove this tissue, without harming the breast skin.  Again, the breast skin and “nipple-areola complex” (NAR) are left intact.

3. What are the benefits? 

As one can imagine, the breast envelope is what you truly see when you look at a breast.  Everyone’s shape is relatively unique, and so preserving this is a good start to preserving what appears to be your breast.  Another significant benefit is that the scar is under the fold (basically hidden), and sometimes (although not guaranteed or even expected) the special nipple nerves are preserved as well (however, general skin sensation is usually maintained).  Of course, there will not be a need to reconstruct the nipple, just the breast mound, and as good as a reconstructed nipple can look, it will never rival Mother Nature.

4. What are the drawbacks? 

This requires special training for the surgeon, and only in the past few years has become accepted treatment for the right patient (also, only recently a part of the basic general surgery training).  This is a technically challenging surgery, as the procedure is done through a (small) opening at the very bottom of the breast (and the breast tissue reaches up to the collar bone).  Although most would (if offered) like to preserve their nipple (NAR), not everyone is a candidate. The blood supply to the NAR could be damaged during surgery, but it will take up to a week to determine this and definitively remove the unhealthy nipple.

5. Who is a candidate for this surgery?

Patients with small (< 2cm usually) tumors away (as best can be determined from pre-operative “pictures” – MRI, mammograms etc.) from the nipple.  Aesthetically, one needs to have a breast shape/ size that we would like to (and can) preserve.  Small to medium (A – C+) cup sizes are usually best.  For the most part, a “breast lift” cannot be combined with a nipple sparing mastectomy (as the lift would jeopardize what little blood supply is left for the NAR).  Smokers will most likely not have a favorable outcome and radiation should not be expected.

Another type of candidate is the “high risk” for breast cancer patient (think Angelina Jolie).  This patient already has the known gene mutation (BRCA 1 or 2) or any number of significant high risk factors (family members with breast and/or ovarian cancer), best determined by a genetic counselor.  A NSM can reduce her chances of developing breast cancer by 95% (that’s as good as it gets)!

6. Who is NOT a candidate for the surgery?

Mostly, the opposite of the above…those with large tumors or tumors near the NAR complex.  Large pendulous breasts (significant “droop”) will not do well due to the large amount of skin that needs to get its blood supply from a rather limited amount of blood vessels (only through the skin).  Anything that will get in the way of blood supply to the NAR can disqualify a candidate, such as smoking, prior or planned radiation, and existing large scars on the breast.

7.  Why don’t all surgeons do NSM? 

This is a rather “loaded” question. Most surgeons in practice were trained with the “dogma” that the nipple contains (cells) ducts that could harbor or develop breast cancer.  Many surgeons today can still remember seeing patients with the “original radical mastectomy” (albeit that was a very long time ago), and the approach to breast cancer has gone through many changes in just the past 40 years. For those who received their training years ago, it’s just difficult to “wrap their heads around” the concept of a NSM. That being said, there has been a lot of research (around the world) in the past ten years to contradict these concerns.  A surgeon needs to be ready to accept this concept, and learn a very new way to approach a surgery that has been ingrained into their head.  The current concepts in breast surgery are geared for a more “oncoplastic” approach (maintaining the natural breast shape in any way possible, while still taking care of the cancer).

8. What should patients ask their doctors when considering NSM or looking for qualified surgeons? 

One needs to look for a surgeon with experience with this surgery, specifically.  The breast surgeon should also be working closely with a plastic surgeon, as there is no point in preserving the NAR without breast reconstruction.   Many plastic surgeons no longer do breast reconstruction, and some that do are not interested in working with a NSM (it is usually the plastic surgeon left to deal with the non-viable nipple, which then requires more surgery to correct).  It can be very helpful to talk to patients who have gone through this procedure vs. questioning a surgeon’s staff as the office staff are basically paid to say good things about the surgeon.  Most patients will have no idea if they are a good candidate for a NSM, so it is necessary to have a consultation with both the general (breast) and plastic surgeon.

To summarize:  One needs to look for the right breast surgeon, one dedicated to and experienced in “Oncoplastic breast surgery,” who works closely with their (equally dedicated and experienced) plastic surgeon, who has the support of their facility, and works as part of a whole team (which also includes Pathology, Oncology, Radiation Oncology, Genetics, Radiology).

For more information on Nipple-Sparing Mastectomy, call Dr. Alissa Schulman of Sovereign Plastic Surgery at 941-366-5476.

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