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Background Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. Methods NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. Results A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. Conclusions Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.

Background The purpose of this study is to identify clinicopathologic factors and/or preoperative MRI vascular patterns in the prediction of ischemia necrosis of the nipple-areola complex (NAC) or skin flap post nipple-sparing mastectomy (NSM). Methods We performed a retrospective analysis of 441 NSM procedures from January 2011 to September 2021 from the breast cancer database at our institution. The ischemia necrosis of NAC or skin flap was evaluated in correlation with clinicopathologic factors and types of skin incision. Patients who received NSM with preoperative MRI evaluation were further evaluated for the relationship between vascular pattern and the impact on ischemia necrosis of NAC or skin flap. Results A total of 441 cases with NSM were enrolled in the current study, and the mean age of the cases was 49.1 ± 9.8 years old. A total of 41 (9.3%) NSM procedures were found to have NAC ischemia/necrosis. Risk factors were evaluated of which old age, large mastectomy specimen weight (> 450 g), and peri-areola incision were identified as predictors of NAC necrosis. Two-hundred seventy NSM procedures also received preoperative MRI, and the blood supply pattern was 18% single-vessel type and 82% double-vessel pattern. There were no correlations between MRI blood supply patterns or types of skin flap incisions with ischemia necrosis of NAC. There were also no correlations between blood loss and the pattern or size of the blood vessel. Conclusion Factors such as the type of skin incision, age, and size of mastectomy weight played an important role in determining ischemia necrosis of NAC; however, MRI vascular (single or dual vessel supply) pattern was not a significant predictive factor.

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.

Background The current study aims to evaluate the nipple and skin sensation following nipple-sparing mastectomy (NSM) and identify patient-, surgical-, or treatment-related factors affecting nipple or skin sensation in this cohort. Methods Patients who received NSM with postoperative nipple and skin sensation test evaluation at a single institution over the past 10 years were retrospectively retrieved from a prospectively collected breast cancer surgery database. Results A total of 460 NSM procedures were included in this current study, with the mean age of 48.3 ± 9.1. Three-hundred eighty-three (83.3%) patients had breast reconstructions. One-hundred seventy-four (37.8%) received conventional NSM (C-NSM), 195 (42.4%) endoscopic-assisted NSM (E-NSM), and 91 (19.8%) robotic-assisted NSM (R-NSM) procedures. For nipple sensation assessment, 15 (3.3%) were grade 0, 83 (18.2%) grade I, 229 (49.7%) grade II, and 133 (28.9%) grade III (normal sensation), respectively, with mean grade score of 2.1 ± 0.7. The preserved (grade III) nipple sensation rate was 36.2% (63/174) in the C-NSM group, 26.7% (52/195) in the E-NSM group, and 19.7% (18/91) in the R-NSM group ( P  = 0.06). The “time since surgery to last evaluation” was significantly longer in the C-NSM group (45.6 ± 34 months) or E-NSM group (44.7 ± 35.8 months) as compared to R-NSM group (31.8 ± 16 months, P  < 0.01). In multivariate analysis, peri-areolar incision showed higher grade of nipple sensation ( OR : 2.1, P  = 0.02) compared to upper outer quadrant incision, and longer follow-up time post-NSM showed significant improvement of nipple or skin sensation (> 60 months vs. ≦ 12 months: nipple odds ratio (OR) = 5.75, P  < 0.01; skin, OR  = 1.97, P  < 0.05). Conclusion Our current analysis showed some factors to be related to postoperative nipple or skin sensation, and longer “time after surgery” was associated with significant improvement of nipple and skin sensation in patients who received NSM, regardless of the surgical approaches. Synopsis Our current analysis showed a significant portion of patients with decrease or loss of nipple or skin sensation after nipple-sparing mastectomy (NSM). Several factors associated with preserved nipple or skin sensation were identified, including age, surgical methods, surgical wound location, and association of time from surgery showing that improvement of partial nipple or skin sensation was evident after a longer follow-up. Highlights • Diminished or loss of nipple sensation had been reported in 10–75% of patients who received nipple-sparing mastectomy (NSM). • “Time from surgery to last evaluation” was a significant factor associated with sensation recovery or preservation in nipple or skin sensation post NSM. • Skin incisions and types of operations (conventional versus endoscopic or robotic assisted NSM) were highly correlated with nipple and skin sensation post-NSM. • Nipple ischemia necrosis grading was unrelated to preserved or lost nipple sensation post-NSM. • Post-mastectomy radiotherapy was not associated with nipple or skin sensation post-NSM.

Background Robotic nipple-sparing mastectomy (RNSM) has emerged as a new treatment option for breast cancer and risk-reducing mastectomy (RRM) for women who have a high risk of pathogenic variants. Even though several studies have reported that RNSM is a feasible procedure, some argue that it should only be performed by specialized surgeons, and data on oncologic outcomes and patient-reported outcomes (PROs) are limited. Recently, the United States Food and Drug Administration and several surgeons warned that robotic breast surgery should be performed only by specialized surgeons and recommended that the benefits, risks, and alternatives of all available treatment options be discussed with patients so they can make informed treatment decisions. The Korea Robot-Endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG) has been established to evaluate, standardize, and teach this state-of-the-art procedure. We have designed a multicenter prospective cohort study entitled Mastectomy with Reconstruction Including Robot Endoscopic Surgery (MARRES) to report surgical, PRO, and oncologic outcomes. Methods MARRES is a multi-institution cohort study prospectively collecting data from patients undergoing mastectomy and reconstruction. The patient inclusion criteria are adult women older than 19 with breast cancer or a high risk of breast cancer (patients with BRCA1/2 , TP53 , PALB2 mutations, etc.), who have scheduled therapeutic or RRM and want immediate reconstruction. Surgical outcomes, including pre- and postoperative photos, oncologic outcomes, cost-effectiveness, and PRO, are collected. The primary endpoints are postoperative complication rates within 30 postoperative days and the Clavien-Dindo grade of postoperative complications within 180 postoperative days. The secondary endpoints are 5-year postoperative recurrence-free survival and cancer incidence rate (for those who underwent RRM), patient satisfaction with reconstruction expectations preoperative (baseline) and results within 6 to 12 postoperative months, surgeon satisfaction with postoperative results in 6 postoperative months, and cost-effectiveness of the definitive surgery. Patient recruitment will be completed in April 2025, and the target number of enrolled patients is 2000. Discussion This study will provide evidence about the surgical outcomes, oncologic outcomes, and patient satisfaction with RNSM and endoscopic nipple-sparing mastectomy (NSM), compared with conventional NSM. Trial registration ClinicalTrials.gov Identifier NCT04585074. Registered April 8, 2020.

With the popularity of breast screening, more and more intraductal papillary lesions (IDPL)were detected by ultrasound or mammography, which is a spectrum of diseases ranging from benign to malignant lesions. Patients with pathological nipple discharge (PND) may indicate IDPL, but it is difficult to clarify their biological characteristics before the operation. As to patients with IDPL without PND, it is even an enormous challenge to differentiate their benign or malignant characteristics. Therefore, to avoid inadequate treatment, it is necessary to analyze the clinicopathological and imaging characteristics of patients with papillary lesions before surgery for the preliminary diagnosis of benign or malignant papillary lesions. 267 cases of IDPL with or without PND, namely PND group and non-PND group, were studied using continuous clinical data from October 2020 to September 2023. We analyzed the clinicopathological and imaging characteristics in the two groups of patients with malignancy compared with benign patients. Meanwhile, these characteristics were analyzed in malignant papillary patients with PND or not. 267 patients were pathologically diagnosed with IDPL during three years, accounting for 15.4% of surgical cases of the same period. There were 55 patients with malignant lesions (20.6%), including 28 cases in the PND group (16.5%) and 27 cases in the non-PND group (27.8%), and the incidence of malignant lesions was higher in the non-PND group than that of the PND group. There was a close correlation between age and malignant lesions in the two groups; the number of patients older than 50 years in malignant patients (74.5%) exceeded that of benign patients (42.5%). There were nearly one-third of malignancies in patients with nipple bloody discharge, and the rate increased to 50% when the patient was older than 50 years, but the malignant rate was meager in patients without bloody discharge. There were some factors relating to malignancy in non-PND patients, including age, lesion size, the distance from the nipple to the lesson (DFNL), and abnormal mammogram; there was a significant difference in this positive manifestation between benign and malignant patients. In malignant intraductal papillary lesions, 40.8% of the cases were invasive carcinoma in the non-PND group, higher than in the PND group (10.7%). Meanwhile, immunohistochemistry was more likely to be hormone receptor-positive (92.6%) and Her-2 negative in the non-PND group, compared with the PND group. Breast IDPL is a common disease, among which malignant lesions are higher than reports in previous literature. There are some clinical and imaging manifestations indicating malignancy; patients more than 50 years old with bloody nipple discharge are at high risk of malignancy. When old non-PND patients have more significant lesions, remote DFNL, and abnormal mammograms, there is a high probability of malignancy in them. Although there are different biological characteristics in malignant IDPL with or without PND, they are all low-grade malignancies compared with traditional breast cancer.

PurposeIndications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion.MethodsThe panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology.ResultsConsensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference.ConclusionsIn case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques.

IntroductionAn inverted nipple can cause significant functional and psychologic disturbance to women. The holy grail of any surgical technique to correct this is to restore adequate nipple projection and at the same time, try to preserve lactation and nipple sensation. We describe our experience using an inferior dermal nipple-areolar interposition flap to correct the inverted nipple alongside with selective release of the lactiferous ducts of the nipple.Materials and MethodsWe have employed this technique successfully in 97 cases of inverted nipples in 60 patients with follow-up periods of up to 2 years. Twenty-three of them had unilateral inversion, and 37 of them had bilateral nipple inversion.ResultsThe appearance of the nipple was good to excellent. Seventy to 80% of the initial postoperative nipple projection at the end of 1 year was maintained. Postoperative complications included stitch abscess in one patient (n = 1) and an epidermal cyst in another (n = 1). Nipple sensation was preserved in 100% of cases. There was no recurrence of inversion in any of the nipples.DiscussionBy identifying the root cause of inverted nipples in each individual case, and selectively targeting them, we minimize surgical morbidity with a simple technique that avoids any form of traction or compression of the nipple and minimizes the risk of altered nipple sensation.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266.

Background We investigated the perioperative outcome and oncologic safety of performing nipple-sparing mastectomy (NSM) through a single axillary incision (NSM-SAI) compared with performing NSM through a conventional incision (NSM-C). Methods We retrospectively reviewed 725 patients who underwent NSM for breast cancer between January 2010 and December 2023; 333 patients who underwent NSM with immediate reconstruction (IR) were enrolled. Surgical outcomes and oncologic outcomes of NSM-C ( n = 184), NSM performed through SAI with a freehand approach (NSM-SAI-F; n = 92), and with an endoscopic approach (NSM-SAI-E; n = 57) were demonstrated. The risk factors for resection margins, nipple-areolar complex (NAC), and skin flap necrosis were evaluated separately for NSM-C and NSM-SAI. Results NAC and skin flap necrosis occurrence rates among the NSM-C, NSM-SAI-F, and NSM-SAI-E groups were similar (insignificant), regardless of autologous or prosthesis reconstruction. The tumor-to-nipple distance among patients who underwent NSM-C was an independent risk factor for NAC necrosis in the NSM-C group (odds ratio [OR] 6.02, p = 0.007); being overweight and tumor location in the lower breast were risk factors for skin necrosis in the NSM-C group (OR 3.36, p = 0.041; and OR 4.32, p = 0.011, respectively). These risk factors were not associated with the NSM-SAI group. The three groups had comparable positive resection margins, local recurrence-free survival, and distant metastasis-free survival rates ( p = 0.857, 0.543, and 0.975, respectively). Conclusions NSM-SAI combined with IR by the freehand or endoscopic approaches can provide good aesthetic outcomes and oncologic safety for well-selected patients with breast cancer. The risk factors for NAC and skin flap necrosis differ between the NSM-SAI and NSM-C groups.

This study aims to compare the rate of nipple necrosis between the submuscular (SM) versus the prepectoral (PP) implant placement after immediate breast reconstruction (IBR). An institutional review board-approved database was reviewed of patients who underwent nipple sparing mastectomy (NSM) with IBR at our institution between 2016 and 2019. Patients who had SM versus PP IBR were compared. Incidence of nipple necrosis was evaluated between the two groups. A total of 525 NSM with IBR were performed in 320 patients with SM reconstruction in 61% (n ​= ​322) and PP in 39% (n ​= ​203) of the mastectomies. Overall, 43 nipples experienced some form of necrosis with 1% of mastectomies experiencing nipple loss. There was no difference between SM group and PP group at the rate of nipple necrosis (9 ​% vs 7 %, P ​= ​0.71). In patients undergoing NSM with IBR, the rate of nipple necrosis, nipple loss or complications did not differ between groups whether the implant was placed SM or PP, supporting the safety of this newer procedure. •Prepectoral implant reconstruction is regaining popularity as a reconstruction technique•Prepectoral reconstruction can be performed in patients undergoing nipple-sparing mastectomy with no compromise of nipple vascularity•Plastic surgeon training and level of performance will impact the precpectoral reconstruction outcome as surgeons go through the learning curve.