15-146-031-01 By Denise Mann

It was a hot and humid afternoon in Voorheesville, NY, and Washington, DC-based plastic surgeon Scott Spear, MD, stood virtually surrounded by mounted deer, moose, and lions in a big game hunter’s converted garage.

Spear, founding chairman of the Department of Plastic Surgery at Georgetown University Hospital in Washington and past president of the American Society of Plastic Surgeons, was clearly out of his element, but you wouldn’t know it. Not even the beady eyes on the mounted prey could distract him from his mission as he discussed color schemes for nipples and areolas with the CEO of a major tattoo equipment manufacturer and tattoo artist who went by “Huck” and just happened to be covered in tats.

The year was 1984, and surgeons had succeeded in building nipples from scratch during breast reconstruction, but there was one not-so-tiny problem: the coloring of the nipples and areolas was all off.

Spear knew his patients wanted and deserved better, and he knew that the profession could do better, too. He meticulously photographed more than 100 patients’ nipples and sent these images to Huck Spaulding of Spaulding and Rogers, a tattoo manufacturer and distributor in Voorheesville, NY. He hoped that Spaulding could develop a more realistic nipple and areola color palette based on the photos.

Turns out, he could do just that. “We now provide surgeons and tattoo artists with palettes of flesh-toned colors to match nipples and areolas in women of all skin types,” Spaulding says.

Yes, this was a game-changing event, but Spear—an early champion of nipple-sparing mastectomy—had more work ahead of him. There was a time when sparing the nipple would have been technically unfathomable, but as mastectomy and breast reconstruction techniques evolved from the Halsted radical mastectomy and modified radical mastectomy to skin-sparing surgeries, it started to become more of a possibility—at least a theoretical one.

Nipple-sparing or total skin-sparing mastectomy involves removing the contents of the breast sans the skin and/or the nipple-areola complex, he says. “It’s similar to the architectural concept of historic preservation where architects will remove the inside of building, but keep the façade.”

This makes a big difference for women. “When a woman faces a mastectomy, she is often equally or more upset about losing what is visible, not just the inside of the breast,” he says. “Women who have nipple-sparing mastectomies are psychologically better off, in terms of self-esteem and sense of self, than those who have had the nipple removed.”

One of the main concerns with keeping the skin and nipple intact was the potential for cancer occurrence or recurrence. Breast surgeons were reluctant to spare the nipple in the context of risk reduction, and downright opposed it in the presence of diagnosed breast cancer, Spear says.

It was a fairly ingrained resistance, he says. “The breast surgeons would say leaving the nipple is riskier and would quote numbers without a specific source, and tell women that if they keep the nipple, the chance of breast cancer returning to the nipple is 5% and if they remove it, the chance goes down to 1%,” he says.

A landmark study published in the New England Journal of Medicine in 1999 ultimately helped further the case for prophylactic mastectomy, but not specifically for retaining the nipple. Researchers at the Mayo Clinic in Rochester, Minn, reported that 639 women of moderate and high risk for development of breast cancer who underwent prophylactic mastectomy dramatically reduced their risk of developing the cancer. Ninety percent of the mastectomies in this series were nipple sparing, and there was no statistically significant difference in the cancer-preventing benefit whether the nipple was removed or retained, the study showed.

Despite the evidence, study authors called for nipple removal following prophylactic mastectomy.

Spear resurrected that study and re-crunched the oft-quoted numbers, and found that the data showed that, in contrast to the study’s conclusion, the risk of cancer occurrence was, in fact, no worse when the nipple was left intact than when it was removed. The new conclusion served as the basis for what was to become Spear’s stump speech on nipple-sparing mastectomy, one that he has given scores of times both formally and informally over the years.

“Prophylactic mastectomy patients are more amenable to nipple-sparing techniques,” he says. “When you don’t have cancer and you are simply doing a mastectomy because of risk of cancer, there is less concern about leaving cancer,” he says.

“With the camel’s nose now in the tent, we moved from nipple-sparing in prophylactic patients to cancer patients,” he says. “Rationality trumps superstition. As long as you get all the cancer, it doesn’t matter if you keep the nipple.”

The risk of developing breast cancer in the nipple is very low, he says. In one 2011 study, Spear and colleagues reviewed the 169 nipple-sparing mastectomies performed over 20 years at Georgetown University Hospital; and found there were no cancer recurrences and no new cancers on average for 2½ years after women underwent the procedure.

Nipple-sparing techniques really started to catch on after the publication of this and other studies. “It accelerated from ‘Nobody does it’ to ‘Why not do it?’?” he says. “Some 30 years ago, this was near impossible to fathom.”

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Why Can’t We All Just Get Along?

The debate and disagreement over nipple-sparing mastectomy could have been divisive, but Scott Spear, MD, worked to move breast specialists closer together with the Breast Cancer Coordinated Care Conference.

Now in its fourth year, the conference brings breast surgeons, plastic and reconstructive surgeons, and radiation oncologists to the table to talk about treatment planning and coordination. Here, experts hash out the pros and cons of various procedures, and share their knowledge and expertise with one another.

“We discuss what the plastic surgeons think breast surgeon can do to make plastic surgery work better and how plastic surgeons need to work with breast surgeons in terms of timing,” Spear says. “The breast surgeon is probably the captain of the ship, but we need to help them understand how they can influence the quality of the result even in the performing of mastectomy.”[/sidebar]

Why Not Spare the Nipple?

Nipple-sparing mastectomy is not appropriate for all women with breast cancer, but Spear’s work has helped to refine the patient population that stands to benefit. There are certain anatomic and oncologic characteristics that will necessitate removing the nipple, including the size of the cancer, the size of the breast, and the location of the cancer within the breast, he explains.

The initial recommendations were as follows: On clinical assessment, tumors should measure 3 cm in diameter or less, be located 2 cm away from the edge of the nipple-areola with clinically negative axillae or sentinel node negative, no skin involvement, and no inflammatory breast cancer.

If possible, women considering nipple-sparing mastectomy should undergo preoperative magnetic resonance imaging of the breast to further exclude nipple involvement. The final decision to spare the nipple must ultimately wait frozen and then definitive pathologic section, he says.

When using the above criteria, the risk of occult tumor in the nipple should be 5% to 15%. A frozen section of the base of the nipple will identify many, if not most, of those occult tumors; and that the risk of occult tumor still being present in patients screened with frozen section-negative findings is as low as 4%, he says.

This shifting paradigm has sired other changes as well. “Some of the enthusiasm around direct-to-implant reconstruction has been made possible by nipple-sparing techniques, as now you just fill the old space rather than stretch a smaller one,” he says.

Other advances, such as the widespread use of acellular dermal matrices (ADMs) to create a natural shape from the beginning, and the introduction of Indocyanine green fluorescent angiography, which allows surgeons to look at circulation in skin in real time during surgery to make sure it is healthy enough for an implant, have helped improve the quality of results and the safety of the surgery, he says.

With more options than ever, choosing the most appropriate breast reconstruction procedure has become more important and thought-provoking, he says. “Often the circumstances pretty quickly send you in one direction or another,” Spear says. “A woman who is 35, has normal body weight and height, a nice figure and C-cup and is BRCA-positive, will most likely undergo a nipple-sparing mastectomy,” he says.

“If you have a patient who has a body mass index of 30, a double D breast who has had radiation and now is experiencing recurrence, you would likely do a free-flap,” he adds.

“The ability to reconstruct the breast except when radiated is so much better than 5 or 10 years ago. It is actually mind-boggling,” he continues. Still, there is always some room for improvement.

“What could make it even better would be to learn how to do a mastectomy with less damage to skin and fat,” he says. To that end, a plasma blade allows for bloodless cutting without thermal injury to tissue. “Seeing that used more widely would also be a good thing,” Spear says.

“Intraoperative or partial breast radiation would be another boom. Instead of radiating the entire breast, we could just radiate the spot where the lump is removed, which will mean less damage to the patient and will make it easier to reconstruct the breast after lumpectomy and breast conservation,” he says.

“The biggest hindrance to our breast reconstruction results is radiation,” Spear adds. “What I say to patients is that our goal is to leave someone with an A-quality result, but when they have radiation after mastectomy, the goal is a B-quality result.”

Another area of research that may help further improve breast reconstruction outcomes is cellular fat grafting. “At the moment, fat is transplanted as living cells, and can be used to improve the shape of the reconstructed breast. But in the future, it is possible that it may be done using a scaffold that catches the fat cells,” Spear explains. “We would transplant the beehive instead of the bee.”

The future is indeed bright, and many of the changes that have already been realized would not have been possible without Spear, says New York City plastic surgeon and current ASPS president Scot Glasberg, MD.

“He is a forward thinker and an innovator, and the founding father of modern-day breast surgery,” Glasberg says. “He took the basics and developed on them from a technical and scientific standpoint—beyond what we could have imagined.” It is for all of these reasons that Glasberg will present Spear with the ASPS Honorary Citation Award at the 2015 meeting.

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at [email protected].