Nipple-sparing mastectomy (NSM) is appropriate for selected patients with early-stage breast cancer or high breast cancer risk. However, the rate of nipple necrosis after NSM is relatively high (10% to 30%). No study has specifically evaluated whether clinical and technical factors contribute to nipple necrosis after NSM. The objectives of this study were to determine the impact of clinicopathologic and surgical variables on rates of partial and total nipple necrosis after NSM and to compare overall complication rates between NSM and skin-sparing mastectomy (SSM).
The study included 233 cases, 113 had NSM and immediate breast reconstruction and 120 matched (for disease stage, comorbidities, and age) cases of SSM and immediate reconstruction performed at our institution from September 2003 through May 2011. Complications were analyzed using the Fisher’s exact test, and in the NSM group, clinicopathologic and surgical variables were analyzed using Rao-Scott chi-squared tests for relationship with partial or total nipple necrosis.
The overall complication rate was 28% for NSM and 27% for SSM (p>0.99). In patients who did not have axillary surgery (those undergoing risk-reducing mastectomy), the overall rate of complications was significantly higher in the NSM group than in the SSM group (26% versus 9%; p=0.06). However, in patients who had axillary surgery (either sentinel lymph node biopsy or axillary lymphadenectomy), the overall complication rate did not differ between the two groups. For NSM, the overall incidence of any (partial or total) nipple necrosis was 20%. There were only 2 cases (2%) with total necrosis. Larger breasts (C cup or larger) were associated with a higher rate of nipple necrosis (34% for C cup; 6% for A and B cup; p=0.003). Smoking (p=0.08) and vascular comorbidities (p=0.09) did not reach statistical significance as predictors of nipple necrosis. The other factors analyzed were not predictors of nipple necrosis.
We found no significant difference in the overall incidence of complications in patients who have NSM compared to those who have SSM. Interestingly, the exclusion of axillary lymphatic surgery in patients undergoing risk-reducing NSM for high breast cancer risk did not decrease the incidence of complications, probably because of the inherent technical complexity of performing NSM in and of itself. Although partial nipple necrosis did occur quite frequently (19%), total nipple necrosis after NSM occurred infrequently (2%). Importantly, patients with breast size of C cup or larger had an increased risk for nipple necrosis after NSM and immediate breast reconstruction.
Clinical Level of Evidence