What is a Nipple Sparing Mastectomy and who makes a good candidate?

09 Jun 2020

Pink Hope invited Oncoplastic Breast Surgeon, Dr Samriti Sood to discuss what a nipple sparing mastectomy is, how it differs from other mastectomies, what makes a good candidate for this type of surgery, and if it is a safe option when treating breast cancer or as a preventative surgery Nipple Sparing Mastectomies.

You can view the recording of this interview here.

What is a Nipple Sparing Mastectomy?
During a Nipple Sparing Mastectomy, the breast tissue is removed through a surgical process that preserves the skin, nipple and areola, creating an envelope of skin that an implant can be placed into providing an appealing cosmetic result with the look and feel of a normal breast and also a closer replication of the other breast if the mastectomy is unilateral.

How does this differ to other types of mastectomy?
Many years ago, a mastectomy was a very invasive and debilitating surgery called a modified radical, or radical mastectomy but over recent years mastectomy surgery has become less invasive and surgeons have worked hard to provide patients with improved quality of life and psychosocial outcomes.

Nipple sparing mastectomy is a very complex surgery due to the need to preserve and protect blood supply to the nipple and the skin overlying the breast, however, the cosmetic results achieved for women are excellent.

Who is a candidate for a Nipple Sparing Mastectomy?
Unfortunately, this type of mastectomy is unable to be offered to all women, the predetermining factor is the ability to preserve blood supply.

This means that this mastectomy is offered to women that have very little, or no, ptosis (sag) to their breast, so women who are A, B and sometimes C cup are ideal candidates however D cup and beyond are generally not due to the complexity of the surgery and increased risk of losing blood supply to the nipple at this cup size. However, for some women, a nipple sparing mastectomy may be offered following breast reduction surgery, this is a riskier procedure hence it needs to be discussed carefully with the woman and it’s more likely to only be offered by experienced and well trained oncoplastic surgeons.

Another determining factor is a women’s overall health, the surgery would not be offered to anyone that has any condition that may affect their blood supply, such as badly controlled diabetes or a heavy smoker.

Is this a safe option when treating cancer or having a preventative mastectomy?
This question has been the subject of a lot of recent medical literature, but it is now considered globally to be an operation with a high level of oncological safety. Concerns had previously been that during the process to save the nipple, which is quite complex, there was a risk of leaving trace amounts of breast cells behind, thereby leaving the patient at risk of recurrence, or a cancer, if the surgery was preventative. However, no mastectomy is 100% effective and generally, around 98% of breast cells are removed regardless of the type of mastectomy performed meaning Nipple Sparing surgery does not provide any greater risk.

How is the skin and nipple kept healthy during and after surgery?
An experienced Oncoplastic Surgeon will have developed a technique for this surgery that they trust and have performed many times. The key is to continuously monitor the nipple throughout the surgery to identify any signs of blood supply disruption early, if an issue does occur a decision will be made to place a flat expander into the breast rather than an implant, to reduce the pressure on the nipple and the skin during healing. If this does happen, the expander is replaced with an implant three months later.

Following surgery precautions and a high level of care is taken to protect and promote healing of the skin and nipple. The first week post-surgery is the most vulnerable period, after this however the skin and nipple tend to bounce back quite quickly.

There is a less than 5% risk of a complication where the nipple dies post-surgery. When this occurs, it is generally quite immediate or within 2-3 weeks post mastectomy, and is identified by the nipple turning black and then slowly healing from the bottom up and the nipple sloughing off, like dead skin, if the surrounding skin is healthy then most often this is how the breast is left. However, should the entire thickness of the nipple and the surrounding skin die, further surgery will be required to remove the dead nipple and skin. 

Does sensation return to the skin and nipple post-surgery?
This is very much different for each patient, some women experience long lasting numbness, but some women may experience a return of sensation over time as the nerves regenerate. Skin sensation can return between 6-12 months post-surgery, but a significant number of women can expect to regain no nipple sensation.

What does annual screening look like?
Screening is an annual in clinic assessment with your surgeon where they will check there are no lumps growing under the skin, sometimes there may be a need for an ultrasound, but most often it will be a simple physical check that is enough to ensure the breast is healthy and there are no concerns.

Dr Sood wrapped up our conversation by sharing this piece of advice for a woman considering a nipple sparing mastectomy.

Be comfortable with your decision, take the time to fully understand all of the impacts and expected outcomes and consider the complexity of this particular surgery including the very important two week healing period where your surgeon will closely monitor your recovery to optimise blood supply.