Category: Breast Reconstruction
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.
Patients have great interest in skin sparing and nipple sparing mastectomies these days. Classical mastectomies used an incision across the central breast mound removing the nipple and areola as well as several inches of skin medial and lateral to the areola. This approach gives great access to reliably remove the breast tissue, but because of the amount of skin removed I’d have to replace that lost skin with skin from elsewhere. To replace the lost skin we might use tissue from the abdomen as in a TRAM flap or DIEP flap, or from the back with a Latissimus flap (learn about these flaps in other blogs). Another option was to stretch the local skin with a tissue expander placed under skin and chest muscle. The expander is a fancy balloon that we can slowly fill with salt water over time to stretch the skin out with time. Once the skin and muscle are stretched adequately we can go back and place a breast implant or the patient’s own tissue into that expanded space to make the form of the new breast. A skin sparing mastectomy removes as little extra skin as we can get away with, and a nipple sparing mastectomy keeps all the patient’s skin including the nipple and areola. It’s very important for my patient’s to realize that not everyone is a candidate for a skin sparing or nipple sparing mastectomy. Patient’s with large pendulous breasts have just too much skin to begin with to make a skin sparing type procedure logical. Mastectomies require removal of all the breast under the chest skin leaving thin long flaps of skin. If these skin flaps are fairly long there won’t be enough blood supply to keep the edges healthy. It’s easy to imagine how a very large breast would have much longer skin flaps than the smaller breasted patient so the blood supply entering the flaps don’t have as far to travel through the skin and back.
Patients also have to realize their cancer location or type may make a nipple sparing mastectomy not a good option. If a cancer is located right under the nipple areola your cancer surgeon will want to remove the nipple areola in that circumstance. As a plastic surgeon I always let the cancer surgeon first decide if the patient is even a possible candidate for skin or nipple sparing mastectomy. If the cancer doctor says it’s ok than I can advise the patient about whether it’s a good option relative to there anatomy and reconstructive desires. While keeping your own nipple seems like a great idea on the front end, if your skin or nipple dies due to lack of blood supply it can greatly slow down your recovery, be an emotional hurdle you didn’t need, or require another procedure. No one wants more operations, or extra hiccups in their recovery if they can be avoided. An option to make the blood supply more reliable to the nipple is a procedure called a “nipple areolar delay”. This is a simple procedure to cut just enough of the blood supply to the nipple areola weeks prior to the mastectomy so that the blood supply to the skin has improved and gotten stronger so the nipple skin is healthier at the time of the mastectomy. To learn more about the delay phenomenon and it’s use in nipple sparing mastectomies read my blog on Breast Reconstruction: Nipple Areolar delay.