The concept of the NSM was popularized by Freeman in the 1960 s and 1970s.21
The procedure was referred to as a subcutaneous mastectomy. Breast tissue was left along the undersurface of the NAC to protect the blood supply to the nipple and areola. Many patients underwent these procedures at the Mayo Clinic in Rochester, Minnesota, for approximately 20 years. Subsequently, Hartmann et al. published the follow-up data on these patients from the Mayo Clinic and found that prophylactic subcutaneous mastectomy did have a protective benefit by reducing the risk of breast cancer in both high-risk and moderate-risk groups by 81–94%.22
In their later study, which was based on the same patient population, a similar risk reduction was found in patients with BRCA1
However, the subcutaneous mastectomy fell out of favor in the United States.
The use of NSM for the treatment of breast cancer grew in the 1970 s and 1980s.24
In 2003, Gerber, Krause, and colleagues from Germany reported their experience with NSM.1
At 59 months, there were 6 recurrences (5.4%) in the 112 NSMs and 11 recurrences (8.2%) among the 134 women who had the NAC removed with their mastectomies.1
After the report by Gerber et al., other single institutions have reported their experience with NSMs.2
A review article by Voltura et al. found local recurrence rates with NSM showed an equivalency to SSM.7
They thought that patients undergoing neoadjuvant chemotherapy were acceptable candidates for NSM. They did not core out the nipple. Their selection criteria included tumors ≤4.5 cm that were also ≥2.5 cm from the edge of the areola. They excluded patients with bloody nipple discharge, inflammatory breast cancer, or tumor involvement of the NAC.
Garcia-Etienne et al. found that in properly selected cases local control after NSM is consistent with that of total standard mastectomy and SSM.8
They stated an opinion that local failure is a manifestation of tumor biology rather than preservation of the NAC. They reviewed 1826 NSMs performed for breast cancer treatment published in the recent literature and found only three local recurrences (0.16%) within the NAC.6
They thought that preoperative evaluation for NSM should include complete imaging studies, preferably breast magnetic resonance imaging. They included in their selection criteria tumor size of up to 5 cm and a tumor to nipple distance of ≥2 cm.
Rusby et al. have published the most recent review of NSM in the literature.12
They also found recurrence rates of <5% in properly selected patients undergoing NSM for breast cancer treatment. The incidence of cancer in the retained nipple after risk-reducing mastectomy is <1%. Nipple necrosis rates were 8 and 16% for total and partial necrosis, respectively. They also reviewed some of the literature on terminal ductal lobular units in the nipple. The incidence was reported to be between 9% and 17%, with most of the terminal ductal lobular units at the base of the nipple papilla.26
They cautioned against fixed-volume reconstructions after NSM because of a higher incidence of NAC necrosis.
The major limitations of our series are the limited numbers of cases and short follow-up. However, comparing our initial series of 43 patients with 60 AS or NAS mastectomies with the published literature showed many similarities. We have treated the full spectrum of breast cancer, excluding patients with locally advanced or inflammatory tumors as well as those involving the NAC.
Only 2 patients (3.3%) had full-thickness nipple/areola loss because we saved the NAC. Our results compared favorably with those of the published literature on NAC loss.7
The 11 patients who underwent postoperative adjuvant radiotherapy had no complications. This experience parallels our outcomes with SSM who had first-stage reconstructions with tissue expanders. With both NSM and SSM, we replace the tissue expanders with either saline or silicone implants 4 months after the completion of radiotherapy.
In our series, we have had only one case of local recurrence of breast cancer. The recurrence was Paget’s disease of the areola diagnosed 34 months after an AS mastectomy. The patient was treated with resection of her areola and has had no further recurrence of cancer 13 months later. Our short-term recurrence rate compares favorably with similar series in the literature.2
Our initial experience with AS or NAS mastectomies in the community setting has taught us several things. First, the performance of NSM can be effectively accomplished in the community setting. This procedure requires a team effort. Determining suitability for NSM is a joint process between the breast and the plastic surgeon. Patients with moderate to marked ptosis were not excluded because we perform a modified mastopexy to correct the ptosis as part of the NSM mastectomy.
In our series, inclusion criteria for NSM are nearly the same as those for SSM (multicentric disease, extent of disease too large for breast conservation, and patient choice). Exclusion criteria for NSM in our series included inflammatory breast cancer, involvement of the NAC, and locally advanced breast cancers.
The high viability rate of the NAC is likely the result of three factors. First, we use primarily inframammary incisions that spare the medial and lateral vessels supplying the skin of the breast. Second, the subcutaneous fat plane of the breast is preserved, which then preserves the microcirculation of the breast skin and areola. The subcutaneous fat layer is only thinned in the area of the cancer. Third, most of the reconstructions were performed with tissue expanders and not fixed-volume implants or autologous flaps, which create increased pressure in the subcutaneous space.
In conclusion, NSM can be safely performed in the community hospital setting with low complication rates and good short-term results. The inframammary approach for NSM in our hands has been a safe and reliable procedure that does not adversely affect the viability of the NAC. In addition, our experience with the inframammary approach results in less visible scars, which we think provides better aesthetic results.
We have adopted the following indications and contraindications for NSM: indications are candidates for SSM and patient choice, and contraindications are involvement of the NAC, and presence of inflammatory and locally advanced breast cancers.