Expanded Indications and Improved Outcomes for Nipple-Sparing Mastectomy Over Time

Background: Demand for nipple-sparing mastectomy (NSM) has increased. The authors’ initial NSM guidelines included risk reduction and cancers 2 cm or smaller located more than 2 cm from the nipple. The relative contraindications included obesity, large and/or ptotic breasts, and prior radiation. This study aimed to evaluate changes over time in NSM indications, surgical approach, and early outcomes. Methods: After institutional review board approval, the study identified 354 patients scheduled for 588 NSMs, 341 (96 %) of whom underwent 566 NSMs. Changes across time [early (2009–2010), mid (2011–2012), and recent (2013–6/2014)] were assessed using tests for linear trend. Results: For patients undergoing reconstruction, NSMs increased from 24 % (early) to 40 % (recent) (p = 0.004). Among the NSM patients, average body mass index, proportion with bra cup sizes of C or larger, and prior radiation increased significantly over time. Performance of NSM for tumors 2 cm or less from the nipple increased from 5 to 18 %, and after neoadjuvant therapy, from 8 to 21.5 % (p = 0.02). Use of inframammary, radial, and reduction-type incisions increased over time, together with intraoperative laser angiography (both p < 0.0001). Concomitantly, the overall complication rate, complications requiring treatment, and postoperative nipple loss decreased. During a median follow-up period of 19 months, five locoregional recurrences (LRR) were observed, for an estimated 2-year LRR rate of 1.7 % [95 % confidence interval (CI), 0–3.9 %]. Conclusions: Over time, the indications for NSM expanded in terms of patient characteristics, tumor stage, and prior therapy, whereas the complication rates decreased. Excellent short-term outcomes suggest that NSM is a reasonable approach for many risk-reduction and cancer patients without disease in the nipple–areolar complex. Further study is needed to assess long-term aesthetics, patient satisfaction, and oncologic safety.