“Nipple-sparing” mastectomy with autologous breast reconstruction can produce natural-looking results in appropriately selected patients, according to a report in the February issue of Plastic and Reconstructive Surgery.

Jamie Levine, MD, of the Institute of Reconstructive Plastic Surgery at New York University, and colleagues report on their experience with the use of autologous reconstruction after nipple-sparing mastectomy. They performed a total of 85 breast “free flap” reconstructions in 51 women from 2007 and 2011.

About two-thirds of the women had preventive mastectomies; most of these patients had BRCA1/2 mutations. The remaining women underwent nipple-sparing mastectomy after initial examination suggested there was no cancer involving the nipple-areola complex (NAC) area. Most of the reconstructions were done using donor flaps from the abdomen.

Overall, the results were good with relatively low complication rates, the study showed. The most common complication was necrosis of part of the donor flap used for reconstruction, occurring in about 13% of patients. These complications were managed without losing the tissue flap used for reconstruction.

However, several women developed complete necrosis of the nipple area, resulting in loss of the NAC. This complication appeared more common in women with a history of smoking. In two women, there was evidence of cancer involvement under the NAC, which made it impossible to preserve the nipple.

Many of the women later underwent additional surgery, either on the reconstructed breast or at the donor site. In some cases, fat grafting was used to augment the breasts after reconstruction.

Patient-Selection Pointers

PSP spoke with Levine about proper patient selection for nipple-sparing mastectomy with autologous breast reconstruction. “It is a growing knowledge base,” he says. For starters, the oncologic surgeon must be on board. This procedure is more common in prophylactic mastectomy patients, and best suited for women whose breasts are modest or moderate in size. Skin laxity is another important attribute for these women, he says.

“The big thing is to match the size of the breast with tissue available from the abdomen or another area,” he says. Importantly for women with breast cancer, the tumor must be small enough and far enough away from ducts and the NAC. “We are still early in evaluating these patients, and although we do biopsies under the nipple itself, there may be some risks that can’t be defined yet.”

Still, if given the choice, most women want to preserve their NAC. “It goes hand-in-hand with lumpectomy, which became such a huge advance for breast surgery because patients were left with their breast, and the NAC, which when left in place, is able to offer these women the equivalent advance in breast reconstruction surgery.”