Breast Reconstruction: Skin and Nipple Sparing Mastectomies

Patients have great interest in skin sparing and nipple sparing mastectomies these days.  Classical mastectomies used an incision across the central breast mound removing the nipple and areola as well as several inches of skin medial and lateral to the areola.  This approach gives great access to reliably remove the breast tissue, but because of the amount of skin removed I’d have to replace that lost skin with skin from elsewhere. To replace the lost skin we might use tissue from the abdomen as in a TRAM flap or DIEP flap, or from the back with a Latissimus flap (learn about these flaps in other blogs). Another option was to stretch the local skin with a tissue expander placed under skin and chest muscle. The expander is a fancy balloon that we can slowly fill with salt water over time to stretch the skin out with time. Once the skin and muscle are stretched adequately we can go back and place a breast implant or the patient’s own tissue into that expanded space to make the form of the new breast.  A skin sparing mastectomy removes as little extra skin as we can get away with, and a nipple sparing mastectomy keeps all the patient’s skin including the nipple and areola.  It’s very important for my patient’s to realize that not everyone is a candidate for a skin sparing or nipple sparing mastectomy.  Patient’s with large pendulous breasts have just too much skin to begin with to make a skin sparing type procedure logical. Mastectomies require removal of all the breast under the chest skin leaving thin long flaps of skin. If these skin flaps are fairly long there won’t be enough blood supply to keep the edges healthy. It’s easy to imagine how a very large breast would have much longer skin flaps than the smaller breasted patient so the blood supply entering the flaps don’t have as far to travel through the skin and back.

Patients also have to realize their cancer location or type may make a nipple sparing mastectomy not a good option. If a cancer is located right under the nipple areola your cancer surgeon will want to remove the nipple areola in that circumstance. As a plastic surgeon I always let the cancer surgeon first decide if the patient is even a possible candidate for skin or nipple sparing mastectomy.  If the cancer doctor says it’s ok than I can advise the patient about whether it’s a good option relative to there anatomy and reconstructive desires. While keeping your own nipple seems like a great idea on the front end, if your skin or nipple dies due to lack of blood supply it can greatly slow down your recovery, be an emotional hurdle you didn’t need, or require another procedure. No one wants more operations, or extra hiccups in their recovery if they can be avoided. An option to make the blood supply more reliable to the nipple is a procedure called a “nipple areolar delay”. This is a simple procedure to cut just enough of the blood supply to the nipple areola weeks prior to the mastectomy so that the blood supply to the skin has improved and gotten stronger so the nipple skin is healthier at the time of the mastectomy. To learn more about the delay phenomenon and it’s use in nipple sparing mastectomies read my blog on Breast Reconstruction: Nipple Areolar delay.