Staged Nipple Delay Procedure Expands Candidacy for Nipple-Sparing Mastectomy

Xuanji Wang; Jordan Jackson; Christina Weed; Marissa K Boyle; Farin F Amersi; James Mirocha; Armando E Giuliano; Alice P Chung

doi:10.1245/s10434-024-16329-y

Staged Nipple Delay Procedure Expands Candidacy for Nipple-Sparing Mastectomy

Ann Surg Oncol. 2024 Oct 14. doi: 10.1245/s10434-024-16329-y. Online ahead of print.

Authors

Xuanji Wang¹, Jordan Jackson², Christina Weed³, Marissa K Boyle², Farin F Amersi², James Mirocha², Armando E Giuliano², Alice P Chung²

Affiliations

¹ Cedars-Sinai Medical Center, Los Angeles, CA, USA. xuwang12@gmail.com.
² Cedars-Sinai Medical Center, Los Angeles, CA, USA.
³ Franciscan Breast Surgery at St. Michael, Silverdale, WA, USA.

PMID: 39402318
DOI: 10.1245/s10434-024-16329-y

Abstract

Background: Nipple delay (ND) is a staged procedure that improves nipple-areolar complex (NAC) viability in nipple-sparing mastectomy (NSM) patients who are high-risk for NAC or skin-flap necrosis. This study compared postoperative outcomes and risk factors between patients treated with ND-NSM and NSM alone.

Methods: Patient demographics, risk factors for NAC or skin-flap necrosis, tumor characteristics, and operative outcomes were compared between ND-NSM and NSM groups from 2009 to 2023. Univariate and multivariate analyses were performed to identify significant variables associated with NAC or skin-flap necrosis.

Results: Overall, 71 ND-NSM patients and 537 NSM patients were compared. ND-NSM patients had larger breasts (p < 0.01), body mass index ≥ 30 (p = 0.01), prior breast/chest wall radiation (XRT) [p < 0.01], prior breast operations (p < 0.01), less axillary surgery (p < 0.01), more autologous tissue reconstruction over implant-based reconstruction compared with NSM patients (p = 0.02), and more prophylaxis (p < 0.01). There were no statistically significant differences between groups in regard to infection, skin-flap necrosis, NAC necrosis, seromas, and hematomas. No patients in the ND-NSM group had NAC necrosis and 1 patient had skin-flap necrosis, compared with 17 and 13 patients in the NSM group, respectively (p = 0.24). On univariate analysis, prior XRT was associated with increased risk for skin-flap necrosis (p = 0.02). Multivariate analysis showed XRT was associated with skin-flap necrosis (p = 0.02) and any necrosis (p = 0.01). Breast size was associated with NAC or skin-flap necrosis (p = 0.04).

Conclusion: Larger breasts and XRT were risk factors for NAC or skin-flap necrosis; however, despite having more risk factors, ND-NSM patients had very low rates of necrosis. Notably, no nipples were lost. A shared decision should be made with patients regarding the risks and benefits of ND-NSM.

Keywords: Breast cancer; Nipple delay; Nipple-areolar complex necrosis; Nipple-sparing mastectomy; Skin-flap necrosis; Surgical outcome.