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Reconstruction and Nipple Sparing Mastectomy

Women considering mastectomy to treat breast cancer or for risk reduction (prophylactic mastectomy) may be candidates for innovative reconstructive procedures that can significantly improve the appearance of their breasts. Nipple sparing mastectomy (NSM) or as it is also known, nipple-preserving mastectomy, is the most cutting-edge technique of mastectomy presently available. NSM removes the breast gland, but allows a woman to keep her nipple and areola (the pigmented area surrounding the nipple) in place. NSM is intended to improve cosmetic outcomes following mastectomy without compromising cancer care or the effectiveness of risk reduction surgery. When appropriate oncologic and aesthetic criteria are strictly applied, NSM allows women to preserve their nipples and areolas and attain the best possible cosmetic results following mastectomy and immediate breast reconstruction.

While there is some debate about NSM in the medical community, an ever-growing number of studies published in peer-reviewed journals including the Annals of Surgery, Annals of Surgical Oncology, The Breast Journal, Journal of Clinical Oncology, and Plastic and Reconstructive Surgery suggest that NSM can be safely performed in carefully selected patients. While not all women are candidates for NSM, the procedure may be appropriate for the treatment of certain breast cancers as well as for women undergoing prophylactic mastectomy.

Nipple sparing mastectomy is more difficult to perform than skin sparing mastectomy because the ductal tissue directly behind the nipple must be removed, yet sufficient blood supply to the skin and nipple must be preserved while no breast tissue is left behind. For this reason, it is important that women considering nipple sparing mastectomy choose a breast surgeon with experience in this cutting-edge procedure in order to assure both oncologic and cosmetic success.

Like all surgical procedures, NSM has benefits and risks. A woman considering this procedure must discuss it carefully with the members of her breast management team and make a choice that best suits her needs. Though the cosmetic benefits of keeping one’s own nipple and areola are readily apparent, women who are considering NSM must be aware of the potential risks of the procedure. In situations where NSM is either not recommended or desired, a skin-sparing mastectomy is almost always an excellent option that can provide excellent cosmetic results.

BRCA Reconstruction

What do we know about heredity and breast cancer?

In 2026, it’s estimated that approximately 380,000 women in the United States will be diagnosed with breast cancer, and one in eight American women will develop breast cancer in her lifetime (source). However, hereditary breast cancer — caused by a mutant gene passed from parents to their children — is rare. Estimates of the incidence of hereditary breast cancer range from between 5 to 10 percent to as many as 25 percent of all breast cancers (source).

In 1994, the first gene associated with breast cancer — BRCA1 (for BReast CAncer1) was identified on chromosome 17. A year later, a second gene associated with breast cancer — BRCA2 — was discovered on chromosome 13. When individuals carry a mutated form of either BRCA1 or BRCA2, they have an increased risk of developing breast or ovarian cancer at some point in their lives. Children of parents with a BRCA1 or BRCA2 mutation have a 50 percent chance of inheriting the gene mutation. If a patient carries BRCA gene, they can have a lifetime risk of 50-70% of developing breast cancer.

In the event you are diagnosed with a BRCA1 or BRCA2 mutation and have been referred for prophylactic (risk-reducing)  mastectomies, you have several options in breast reconstruction:

Revision After Radiation

Lumpectomy with radiation is commonly the preferred option presented to women diagnosed with breast cancer. Despite the advantages, women are rarely informed of the potential negatives of this approach when it comes to subsequent breast deformities that can result. Some deformities are mild, but in many cases the deformities may be severe. These deformities can be prevented or corrected with judicious oncoplastic surgery to minimize the deformity, and frequently reduction or lifting of the other breast to achieve symmetry. 

Unfortunately lumpectomy surgery, radiation therapy that usually accompanies it, and all too frequently, women treated with lumpectomy and radiation, ends up resulting in severely deformed breasts with associated radiation complications. These complications can range from mild skin issues and tissue contraction to severe tissue breakdown and failure to heal. Even with careful oncoplastic surgery to minimize lumpectomy surgery defects, the effects of radiation may actually worsen over time, creating problems that are not immediately apparent.

Direct Implant Reconstruction

In certain cases, patients may be candidates for direct implant reconstruction. Post-mastectomy reconstruction with a direct to implant, or “one-step” approach, allows for mastectomy and a single-stage reconstruction of the breast in the same operative session. This option is best for patients with good preservation of the breast skin following mastectomy, good skin tone, and moderate sized breasts. A permanent implant is inserted immediately following the mastectomy, forgoing the placement of a tissue expander and subsequent expansion process.

A second stage procedure may still be considered in some cases for minor refinements in contour and symmetry without exchanging the implant.  This usually occurs several months after the first/primary procedure, allowing time for swelling and healing to occur.

Choosing Your Implant

Together with your surgeon, you will decide which implant best suits your individual needs. There are two general categories for implants: saline-filled, and the new generation of silicone cohesive gel-filled implants (“gummy bear” implants). The advantages of gel implants are that they tend to be softer; with a feel that is more like natural breast tissue. Also, gel implants can have less rippling and visibility as compared to saline implants. Both types of implants come in numerous shapes, sizes, and profiles.

In two to three months, the next stage of surgery will be performed to reconstruct the nipple and areola. If desired, additional contouring procedures, such as fat injections, can be performed to adjust breast shape at this third stage.

Oncoplastic Reduction

An Oncoplastic Reduction combines the latest plastic surgery techniques with breast surgical oncology. When a sizable lumpectomy is required that will leave the breast misshapen, the remaining tissue is sculpted to align the nipple and areola and restore a natural appearance to the breast shape. The opposing breast will also be modified or reduced for symmetry.

This is a good option for patients who are candidates for breast conservation therapy or lumpectomy, and are also candidates for breast reduction or mastopexy (breast lift).

How is Oncoplastic Surgery performed?

At the time of your lumpectomy and lymph node biopsy with your breast surgeon, the plastic surgeon will perform a bilateral breast reduction or mastopexy, removing breast tissue from the cancerous breast as well as modifying the contralateral normal breast. This generally involves an incision around the nipple and areola, a vertical incision from the nipple to the lower fold of the breast, and sometimes a horizontal incision hidden in the fold of the breast if breast size is large.

These surgeries are generally one stage procedures. Patients may be outpatient or possibly require one night in the hospital. Recovery time is 3-4 weeks, and most people are able to return to work in that time period.