Mastectomy — the surgical removal of the breast — is a centuries-old procedure that only since the 1970s has become more technically sophisticated and more patient-centered. In recent decades, immediate breast reconstruction done in conjunction with mastectomy provides attractive outcomes that benefit women patients.
The number of women undergoing this reconstructive surgery has increased dramatically over the past 30 years, and the trend for immediate breast reconstruction after mastectomy has grown from 10% in the 1980s to about 90% today. Nipple-sparing mastectomy is performed when the surgeon believes that the nipple-areola complex as well as all of the breast skin can be preserved.
Here, Christine R. Rizk, MD, assistant professor of surgery and a member of our Breast and Oncologic Surgery Division, answers a few of the frequently asked questions about nipple-sparing mastectomy.
Q: What is nipple-sparing mastectomy?
A: Nipple-sparing mastectomy is a mastectomy, or removal of all of the breast tissue, without removal of any of the skin or the nipple or the dark skin around it called the areola. In a traditional mastectomy, the nipple is removed and the dark skin around the nipple is removed, as is some of the surrounding skin.
Benefits of the Procedure
Q: What are the advantages to nipple-sparing mastectomy, aside from cosmetic?
A: The advantage of nipple-sparing mastectomy is significant regarding the cosmesis of the breast. The breast looks virtually unchanged and intact, as there is only a small scar either in the under crease of the breast, what we call the infra-mammary fold, or out toward the arm, but it otherwise looks completely intact.
It is not merely cosmetic, as there is very good data to suggest that women have improved self-esteem and self-body image with nipple-sparing mastectomy. Although plastic surgeons can reconstruct a nipple, it can often lose projection over time, and is never as good as what a woman was born with.
Q: How much sensation does the nipple have after nipple-sparing mastectomy?
A: Sensation after nipple-sparing mastectomy again is variable. Some women — up to 30% to 60%, depending on the particular study — report sensation in the nipple, especially over time. That, of course, is completely not possible with a reconstructed nipple. We will often tell women that there often is significant dulling, but at six months to a year after surgery, a good many women will report erectile function and sensation.
Nipple-sparing mastectomy is an effective treatment in selected patients when performed properly, and it offers the benefits of improved self-esteem and self-body image, plus more.
Q: Is nipple-sparing mastectomy effective in both treating and preventing breast cancer?
A: Nipple-sparing mastectomy is excellent in terms of its effectiveness in treating and preventing breast cancer. It is certainly not a procedure for all women, nor is it a procedure for all women with breast cancer. There are definite criteria for patient selection that need to be met.
Q: Who is a good candidate for nipple-sparing mastectomy?
A: Women with relatively small tumors that are peripherally located in the breast and that are not aggressive tumors are generally good candidates for nipple-sparing mastectomy. We consider the woman’s innate breast. This is certainly a better procedure, from a cosmetic point of view, for a smaller-breasted woman than a large-breasted woman who has a significant amount of ptosis, or what we call drooping.
It is a case-by-case decision to be made between the patient and her breast surgeon. The most critical component is a breast surgeon who is very adept and has significant experience with this procedure.
Q: What patients are not good candidates for nipple-sparing mastectomy?
A: Women with what we call the "big and bad" are not good candidates for the procedure. Women with large tumors that are centrally located and/or with aggressive tumors are not usually candidates for nipple-sparing mastectomy. We also do not recommend the procedure for women who have diabetes, who are smokers, or who have any reason not to heal well; for example, if they have previously had radiation treatment.
Risks of the Procedure
Q: Is nipple-sparing mastectomy safe? What are the risks of having it?
A: Yes, the procedure is generally safe, with the usual risks of having surgery. The specific risks of having nipple-sparing mastectomy include the fact that because we remove all of the tissue behind the nipple — in what we call the nipple core — there can be an interruption of the blood supply to it. As a result, there is about an 8% chance that a woman will actually lose her nipple because it will not get adequate blood flow and heal properly.
A common concern is that women are going to have a higher chance of getting breast cancer at the nipple if it is left. This has clearly not been shown in medical studies. In appropriately selected patients whose surgery is performed with meticulous technique, there is no breast tissue left behind the nipple and, therefore, no increased risk of breast cancer.
Q: What, if anything, is done to minimize the risk of recurrent cancer at the nipple?
A: To minimize the risks of recurrent cancer at the nipple, the procedure must be performed correctly and properly with meticulous technique at the nipple, and all the tissue from the nipple core must be completely removed. We recommend that the nipple core tissue be sent for evaluation by a pathologist while the procedure is being performed (intraoperatively).
If any suggestion of abnormality or cancer is found, then the nipple should be removed. This evaluation by pathology that takes place during the surgery and the possible removal of the nipple must be discussed with patients before they undergo the procedure.
If on the final pathology exam done postoperatively any abnormality in that nipple tissue is found, most physicians believe the nipple will need to be removed at a later time.
The other issue to consider is that the nipple area is the least likely to have a recurrence of cancer because, when the procedure is performed properly, there is only skin left behind, no breast tissue.
As many people may know, the risk of recurrent breast cancer after any type of mastectomy is not zero. A woman who has had a mastectomy can still get breast cancer, although there is a very low risk of recurrence. This is because it is not humanly possible for a surgeon to remove every microscopic cell of breast tissue. The goal, however, of mastectomy is to remove any gross visible breast tissue seen by the surgeon. In contrast, at the nipple all that is left behind is skin.
If we left only skin behind in the remainder of the breast envelope with mastectomy, then there would be concern that the skin will not heal and will fall apart. So, it is very important that a thin layer of fat with blood vessels is maintained in the mastectomy envelope in order to ensure proper healing. All breast surgeons know this is potentially where any microscopic breast tissue may also be left behind in any and all hands.
All told, because only skin and no fatty tissue remain at the nipple after nipple-sparing mastectomy, the risk of recurrent breast cancer is extremely low. In fact, review of the medical literature suggests that in women who had this form of mastectomy and who did have recurrent disease, none of them had it at the nipple core but, as expected, they had it in the original tumor site. This pattern of recurrence is exactly what we see in patients who have other forms of mastectomy.
The risk of breast cancer recurring in women who have nipple-sparing mastectomy is similar to that in women who undergo other kinds of mastectomy, according to studies in the medical literature.
Q: What are the risks of retaining the nipple in mastectomy done to prevent breast cancer?
A: Women who are prophylactically removing their breasts are among the most ideal patients for nipple-sparing mastectomy because they do not fall into that risk of having any tumor, let alone small or peripheral disease, and so often they are very healthy. They also tend to be younger which does in fact help wound healing as women tend to be, in general, healthier when they are younger. They tend not to have co-existing medical conditions like diabetes that come with age.
Simply put, nipple-sparing mastectomy does not increase the risk of breast cancer. There is ample medical literature to support this. The risk of recurrence is similar in those women who do not have nipple-sparing mastectomy.
Q: Does nipple-sparing surgery increase the risk of breast cancer recurrence?
A: There is very good data to suggest — in fact, in the medical literature there are multiple reports on this with long-term follow-up — that there is no higher risk of recurrence in a woman who has nipple-sparing mastectomy compared to non-nipple sparing or the traditional procedure. Again, for the best outcome, the patient must be an appropriate candidate and the surgeon must be very skilled at doing the procedure effectively, with the ability to remove all of her breast tissue.
Unfortunately, women can have breast cancer after mastectomy. But the possibility of recurrence is the same regardless of whether they have a traditional mastectomy or a nipple-sparing mastectomy, and this has been pretty much proven by medical research.
The Stony Brook Difference
Q: What are the benefits of having nipple-sparing mastectomy at Stony Brook?
A: To offer premier care to patients, the best approach is always a multispecialty highly-selected group of physicians, and this is exactly what we have at Stony Brook, from the breast surgeons who perform the procedure to the pathologists who are analyzing the breast tissue both during the surgery and after it, to the plastic surgeons who are critical to the success of this procedure.
Stony Brook's plastic surgeons are very well versed in how to reconstruct the breast with the nipple in order to allow for maximal cosmesis including symmetry and nipple alignment. The multispecialty group here is very adept and familiar with this procedure. Such skill and experience make a big difference.
Read more about nipple-sparing mastectomy and how it is improving the care of patients, as well as gaining momentum across the country. See the much-publicized findings of the 2011 Sloan-Kettering study.
