Optimizing Nipple Position following Nipple-Sparing Mastectomy

BACKGROUND: The best treatment for nipple malposition following nipple-sparing mastectomy is prevention. This article reviews basic elements for success in nipple-sparing mastectomy and offers an option to patients with grade 2–3 breast ptosis who strongly desire to preserve the nipple. METHODS: Retrospective review identified patients undergoing nipple-sparing mastectomy and immediate reconstruction. RESULTS: Patient selection centered on realistic goals for postoperative breast size, nipple position, and when not to save the nipple. The choice of device considered projection and nipple centralization as equal components and led to wider, lower profile devices selectively for the first stage of reconstruction. In severe grade 2–3 nipple ptosis, an inferior vertical incision or wedge excision was used to enhance nipple position postoperatively. Eighteen consecutive patients underwent 32 implant-based breast reconstructions following nipple-sparing mastectomy with the vertical incision. The average age was 45 years old, and the average body mass index was 26.7. Direct-to-implant reconstruction was performed in 25%, whereas 75% had tissue expander-implant reconstruction. Overall complications included infection (3%) and nipple necrosis (3%) leading to explant in 1 reconstruction. CONCLUSIONS: The final nipple position following nipple-sparing mastectomy can be optimized with preoperative planning. The vertical incision, combined with proper patient selection and choice of device, may increase eligibility for nipple-sparing procedures in patients with grade 2–3 ptosis who desire nipple preservation.