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Breast Reconstruction: Nipple areola delay

Many of the breast reconstruction patients I see are interested in nipple sparing mastectomies. A nipple sparing mastectomy means the cancer surgeon has decided the patient can keep all their natural breast skin including the nipple areola. Certainly keeping your own nipple areola is a nice option; the problem is once the mastectomy removes most of the blood supply coming into the breast’s skin the nipple may not have enough blood to survive. This means as days go by the nipple may darken, dry up & the skin dies a slow death from lack of blood supply. This is what we call “ischemic skin necrosis.” Ischemic is a medical term that means not enough blood supply and oxygen to keep a tissue healthy. Necrosis means it progressed to the point that the tissue didn’t survive. So when someone has a heart attack the heart is “ischemic” with less blood, and if it’s bad enough it’s called a myocardial infection for part of the heart muscle died. So when a cardiologist does a heart catherization they can put in a stent or use the medications to open the vessel blockage affecting the heart. In plastic surgery we can’t do much to help skin with poor blood supply after it happens so there is a good surgical maneuver I can use on the front end. This classic procedure is called performing a delay to the nipple areola skin. Many years ago plastic surgeons realized that if you partially remove the blood supply to an area of the skin, that over the next few weeks the small blood vessels that are still intact open up and get heartier bringing home blood to the injured skin. If my patient is a good candidate for a nipple sparing mastectomy I will often suggest that I do a “delay” procedure several weeks or more prior to the mastectomy to greatly decrease the chance the patient will have any healing problems with the skin of the nipple areola. The delay procedure means I will make a small incision that allows me to separate the nipple areola from the breast underneath for an inch or two around the whole areola. This delay procedure removes the connections to little blood vessels coming up through the breast so that the small blood vessels in the skin get bigger and stronger so when the mastectomy is performed the nipple’s blood supply is already more robust. The delay procedure is a fairly minor operation and often can be performed with local (numbing injections) anesthesia in the office.
Not everyone is a good candidate for a delay procedure. Large pendulous breasts are poor candidates compared to smaller breasted patients. Also a candidate for nipple sparing mastectomy who has a large projecting nipple needs to consider a delay procedure for their nipple is more at risk for ischemia post mastectomy than a small flatter nipple. For information on skin and nipple sparing mastectomy look at that blog.


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