Nipple-Sparing Mastectomy and Reconstruction
Nipple-sparing mastectomy has been a controversial topic in breast cancer and its treatment. Not all women are candidates for this procedure for treatment, and it is necessary to discuss with your general/breast surgeon on your candidacy. In general, women who may fall into this category include those women who do not have cancer at the present time (genetically positive), and low-risk for recurrence of the cancer within the ductal elements (those that lead to the nipple). So, those very early/small tumors that are remote from the central area and do not have a significant ductal component may be candidates. Having said that, it is important to discuss with your general/breast surgeon regarding the oncologic aspect of sparing the nipple, as well as the risks and complications involved with this procedure.
On a reconstructive standpoint, nipple-sparing mastectomies could give an excellent aesthetic appearance, as the natural nipple-areolar complex remains intact, and often times, the incisions are in a remote location from the central area of the breast. Again, it will be important to coordinate the planning with your surgeon and plastic surgeon for optimal treatment, planning, and results. Both immediate implant-based and flap-based procedures have been performed with excellent results. Filling in the volume that is lost during the mastectomy with either an implant or tissue from your own body can produce a superb reconstruction.
Such a procedure is not without its risks, including a significant rate of necrosis of the spared nipple, due to inadequate blood supply to the area. Especially if an implant lies beneath the area, an open wound could potentially seed an infection to the prosthetic device, warranting antibiotic therapy or potential further procedures and/or removal of the threatened implant. Flap-based procedures give the advantage of bringing in a robust blood supply from a remote area that increases the vascularity to the mastectomy flaps. The normal sensation and erectile function of the nipple will be lost, as a nature of the mastectomy. In addition, for women with significant ptosis (sag) of the breast needing repositioning of the nipple-areolar complex to a more appropriate position, a staged procedure may be appropriate to first reposition and then reconstruct the breast, or vice versa. A recent article in the Plastic Surgery Journal reports good results with banking of the complex for use at a later date.
For those who can perform such procedures, the microsurgical flaps (e.g., DIEP, SIEA, TUG, ALT, SGAP, etc) are great ways to reconstruct the breast after a nipple-sparing mastectomy. I have had phenomenal results with these as it recreates the breast with like-tissue as well as having excellent vascularity, thus recreating the most realistic, natural-appearing and feeling reconstructed breast with a real nipple-areolar complex.
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