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The nipple is part of the lactiferous system1 whereas the areola is a form of pigmented skin, anatomically close but functionally different. For mastectomy, common surgical practice varies between complete excision and preservation of the nipple—areola complex. Two examples of these extremes are given, both giving unsatisfactory results, and a third case in which the differences between nipple and areola were exploited in the NEAT procedure—nipple excised and areola retained.
A woman aged 51 had extensive microcalcification on her left mammogram. She was treated by total mastectomy and subpectoral implant with complete preservation of the areola and nipple. Histological examination showed complete clearance of high-grade ductal carcinoma-in-situ (DCIS) with no evidence of tumour in the separately submitted subareolar tissue. All twelve axillary lymph nodes were free of tumour. One year later she developed left nipple discharge and there were adenocarcinoma cells on the smear. The nipple, excised alone, showed extensive high-grade DCIS of the comedo type with large areas of central necrosis, associated with calcification.
A woman of 51 was referred with nodularity in the upper and outer quadrant of the right breast. On mammography there was widespread malignant microcalcification, and clinical examination showed carcinoma cells. A Patey mastectomy was performed with insertion of a subpectoral implant. Skin closure was tight and with adjuvant radiotherapy the aesthetic result was not ideal. On histological examination there was extensive high-grade DCIS with a comedo pattern, with several small foci of grade III invasive carcinoma, the largest 1 cm in diameter. The nipple and areola showed no intrinsic abnormality. Fourteen of nineteen axillary lymph nodes showed metastatic carcinoma.
A woman aged 68 had a breast lump which proved to contain a duct papilloma with associated papillomatosis. Five years later a second right breast mass was removed, which contained a papilloma. Further biopsies from the right breast at eight and nine years also showed papillomatosis. At eleven years from the original presentation a benign duct papilloma was removed from the left breast. Two years after this, another right-sided papilloma was excised, and the surrounding breast tissue contained a 3 mm focus of high-grade DCIS with incomplete margins. The patient was counselled about the risk of breast cancer associated with bilateral papillomatosis. After considering the options, she opted for bilateral mastectomy with excision of the nipple but retention of the areola. The breasts were reconstructed with subpectoral biodimensional anatomical permanent expander implants (Figure 1).
Preservation of the entire nipple—areola complex has been reported safe after mastectomy3, but concern persists because of the presence of mammary ducts within the preserved nipple and areola4. The principle behind the NEAT procedure is that these tissues are functionally different; in particular, the accessory mammary glands in the areola are not connected by ducts with breast tissue2.
The technique is especially suitable for prophylactic mastectomy. Relative contraindications are deep-sited central tumours and extensive multifocal disease; absolute contraindications are Paget's disease, peau d'orange, clinical evidence of subdermal infiltration, and locally advanced breast cancer.
In a case of breast cancer, what is the likelihood that carcinoma is present or will develop in the retained areola? The risk is likely to be greatest in patients with large primary tumour size and retro-areolar location, multifocal disease and dermal invasion despite apparent clinical areola sparing5. The key to success is careful selection.
NEAT is a simple modification of an accepted mastectomy technique that facilitates tension-free skin closure for immediate breast reconstruction, in particular for implant breast reconstruction without a myocutaneous flap. In breast reconstruction including a myocutaneous flap, the presence of the pigmented areola, incorporated into the transposed flap or as part of the principal surgical incision, can improve the aesthetic result without compromising the principles of cancer surgery.