Nipple-sparing mastectomy
Nipple-sparing mastectomy (NSM), also known as nipple delay, is one of the surgical approaches for treating or preventing breast cancer.
[1] By preserving the NAC, NSM has provided patients with higher cosmetic expectations and the opportunity to undergo a mastectomy while maintaining a more natural appearance.
[8] NSM is generally safe involving a low risk of necrosis of the NAC or surrounding skin due to interruptions of blood supply to it.
[10] The increased rates have an association with risk factors, including ptotic breasts, periareolar scars, large cup size, and previous radiation.
After the identification of the BRCA gene in the 1990s,[11] together with the reintroduction by Hartmann et al. in their published research,[12] the procedure regained popularity.
[14] Nevertheless, in the same year, a critique of Spear challenged this conclusion by presenting a case of a patient with macromastia who underwent NSM safely following a pre-mastectomy delay procedure.
[16] This approach not only achieves post-mastectomy nipple positioning but also avoids the potential drawbacks associated with a separate reduction mammoplasty followed by NSM or a specialized delay procedure.
NSM was ideally aimed at small breast cancer where the location of tumour is far away from the Nipple Areolar Complex (NAC), and without clinical lymph node involvement.
[4] The intraoperative frozen section is highly specific and moderately sensitive for identifying positive sub-areolar biopsies in NSM.
[22] The incision can be displaced 4 cm medially if the internal mammary arteries are desired as the recipient vessel for autologous reconstruction.
[7] Through the whole procedure, the NAC is preserved by dissecting the tissues away from the underlying structures to maintain the blood supply and nerve connections to the nipple.
[8] If any hypotensive situation occurs in patients, intravascular fluid injection is required for replenishment of blood pressure.
[27] Mental health education and self-compassion are important as a protective mechanism for body image disturbance and psychological distress.
[28] However, this surgical approach provides greater psychological benefits than other mastectomy due to the preservation of the NAC and women’s body image.
BMI, breast mass, and sternal notch to nipple length are more adversely affecting the risk of necrosis.
[34] The retroareolar tissue is not removed completely and thus more terminal duct lobular units are left in patient’ s body, which induces higher oncological risk.
